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PRACTICAL   SAf^ITATlON 

A  HANDBOOK  FOR 
PKACTITIONERS  OF  MEDICINE 


BY 

FLETCHER  GARDNER,  M.  D. 

MAJOR  MEDICAL  CORPS,   INDIANA  NATIONAL  GUARD;  FIRST  LIEUTENANT 

MEDICAL   RESERVE   CORPS,   UNITED  STATES  ARMY;   HEALTH 

COMMISSIONER  OF  MONROE  COUNTY,  INDIAN^l,' 


ILLUSTRATED 


ST.   LOUIS 
C.  V.   MOSBY  COMPANY 

1916 


Copyright,  1915,  by  C.  V.  Mosby  Company 


XA4Z.S 


Prenn    of 

0.   V.  Mosby  Company 

ISt.  Louis 


TO 

HARVEY  WASHINGTON  WILEY,  M.D.,  Sc.D., 

Whose  Services  to  the  Cause  of  Sanitation 

Need  No  Encomium, 

This  Book  is  Respectfully  Dedicated 

By  the  Author 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/practicalsanitatOOgard 


PREFACE  TO  FIRST  EDITION. 

This  book  was  designed  to  fill  a  vacancy  in  literature.  Up  to 
the  present,  there  has  never  been  a  serious  endeavor  to  provide 
within  the  covers  of  a  single  moderate-priced  volume,  a  plain, 
non-technical  exposition  of  the  duties  of  the  health  officer,  written 
by  one  experienced  in  the  routine  and  emergencies  of  the  local 
sanitary  service  and  familiar  with  the  needs  of  the  local  health 
officer.  It  is  compiled  from  many  sources,  and,  while  it  contains 
much  of  the  personal  observation  of  both  authors,  it  is  perforce 
comparatively  unoriginal,  since  it  must  present  the  established 
views  and  methods  in  combating  disease  and  not  ideas  of  the 
future.  It  aims  simply  to  provide  a  safe  way  for  the  health  officer 
to  meet  any  emergency  which  may  arise.  Since  sanitary  officials  in 
small  places  out  of  the  reach  of  libraries  are  most  in  need  of  such 
a  work,  and  since  they  are  illy  paid,  the  authors  have  endeavored 
to  provide  a  book  at  a  moderate  price.  Hence,  much  that  is  of 
interest  to  the  expert  has  been  excluded,  while  much  that  to  him 
is  axiomatic  has  been  included. 

Since  treatises  on  tropical  diseases  are  not  ordinarily  to  be 
found  in  small  libraries,  several  of  these  diseases  not  now  known 
to  occur  in  the  United  States,  but  which  are  capable  of  dissemina- 
tion here,  are  included. 

The  parts  of  this  book  dealing  with  Epidemiology  and  General 
Sanitation  are  the  work  of  Dr.  Gardner,  with  the  exception  of  the 
chapters  on  Milk  and  Water,  which,  with  Part  III,  are  the  work 
of  Dr.  Simonds. 

If  this  volume  aids  the  health  officer  in  solving  his  problems, 
and  assists  him  in  raising  the  standard  of  the  public  health,  it  will 
fulfill  the  one  desire  of  the  authors. 

December  1,  1913. 


PREFACE  TO  SECOND  EDITION. 

The  rapid  exhaustion  of  the  first  edition  of  this  book  has  made 
necessary  the  preparation  of  a  new  and  largely  revised  edition. 
While  the  original  purpose  of  the  book  was  to  provide  a  handbook 
for  health  officers,  it  was  also  found  useful  by  teachers.  The  pres- 
ent revision,  without  sacrificing  the  former  view-point,  aims  to  make 
the  volume  more  generally  desirable  for  educational  purposes. 

In  the  iDreparation  of  this  edition,  the  author  has  had  the  benefit 
of  criticism  and  suggestions  from  the  former  co-author,  Dr.  James 
Persons  Simonds  of  the  Medical  School  of  Northwestern  University, 
and  Dr.  Aubrey  H.  Straus  of  the  Medical  College  of  Virginia,  to 
whom  the  author  now  extends  his  appreciation  and  thanks. 

With  this  edition  the  former  senior  author  accepts  the  full  re- 
sponsibility for  all  statements  and  opinions  in  the  book. 

F.  G. 

Bloomington,  Indiana, 
October  30,   1915. 


CONTENTS. 

PART  I. 
EPIDEMIOLOGY. 

CHAPTER 

I.    Infectious  Processes 19 

IT.    The  Management  of  Epidemics 24 

III.  Isolation  and  Quarantine 33 

IV.  Isolation  Hospitals  and  Camps 41 

V.    Disinfection         '^^ 

VI.    The  Typhoid  Group ^^ 

Typhoid  Fever,  63;  Paratyphoid  Fever,  67;  Mountain 
Fever,  68 ;  Amebic  Dysentery,  68 ;  Bacillary  Dysentery,  70 ; 
Asiatic  Cholera,  71. 

VII.    The  Exanthemata .     /4 

Smallpox,  74;  Vaccinia,  83;  Chickenpox,  91;  Scarlet 
Fever,  92;  Measles,  97;  Rubella,  101;  Filatow-Dukes'  Dis- 
ease, 102. 

VIII.    The  Diphtheria   Group 1^^ 

Diphtheria,  103;  Influenza,  109;  Whooping  Cough,  112; 
Epidemic  Parotitis,   113. 

IX.    The  Plague  Group H^ 

Plague,  115;  Malta  Fever.  119;  Anthrax,  120;  Glanders 
and  Farcy,  122;  Foot-and-Mouth  Disease,  124;  Hydropho- 
bia, 125. 

X.  The  Yellow  Fever  Group  .      .     .      .  , 128 

Yellow   Fever,   128;    Malaria,    131;    Dengue,    135. 

XI.  The  Septic  Group l^'^ 

Erysipelas,  137;  Tetanus,  139 

T^TXII.     The  Tuberculosis    Group       141 

y  Tuberculosis,   141;   Leprosy,   147 

/         XIII.     The    Typhus    Group 150 

'  Typhus    Fever,     150;     Relapsing    Fever,     152;     Tropical 

Splenomegaly,   154. 

XIV.     The   Meningitis    Group 156 

Acute  Poliomyelitis,  156;   Cerebrospinal  Fever,   159. 

"XV.     The    Venereal  Grout? 166 

Syphilis,   167;   Gonorrhea,   168;   Prophylaxis,   169. 

XVI.     Nutritional   Diseases 1'''2 

Pellagra,  172;   Beriberi,   176;   Scurvj',   178. 

XVII.     The  Ringworm  Group 1"9 

Impetigo  Contagiosa,  179;  Tinea,  179;  Ringworm  or 
Barber's  Itch,  180;  Favus,  180;  Tinea  Versicolor,  180; 
Dhobie  Itch,   180. 


CHAPTER 
XVIII. 


XIX. 


CONTENTS. 

PAGE 

The  Conjunctivitis   Group 182 

Trachoma,  182;  Mucopurulent  Conjunctivitis,  183; 
Gonorrheal  Conjunctivitis,  184;  Ophthalmia  Neonatorum, 
184. 

The  Animal    Parasites 18G 

Flukes,  186;  Tape-worms,  187;  Roundworms,  187;  Itch 
Insect,  197;  Ticks,  197;  Lice,  197;  Bedbugs,  198;  Fleas, 
198. 


PART  II. 
GENERAL  SANITATION. 

XX.     The  Organization  of  the  Sanitary  Service 199 

XXI.     Local  Records  and  Statistical  Methods 202 

XXII.     The  Birth  Record 207 

XXIII.  Morbidity  Reports 214 

XXIV.  Registration  of  Deaths 219 

XXV.     The  Disposal  of  the  Dead 243 

XXVI.     School  Inspection 247 

XXVII.     Factories   and   Workshops 263 

XXVIII.     Institutions   and  Prisons 267 

XXIX.     The   Rat 270 

XXX.     Anti-Fly   Campaigns 280 

XXXI.     The    Mosquito 286 

XXXII.     Prevention  of  Soil  Pollution 292 

XXXIII.  Sewage  Disposal 308 

XXXIV.  Disposal  of  Garbage * 312 

XXXV.     Sanitary  Food   Inspection 315 

XXXVI.     Milk 325 

XXXVII.     Water        345 

XXXVIII.     Nuisances 354 

XXXIX.     Miscellaneous  Sanitary  Laws 359 

XL.     Public   Emergencies 361 


PART  III. 
LABORATORY  METHODS. 

XLI.     Pathological  Materials 365 

Dii)htheria,  367;  Tuberculosis,  374;  Typhoid  Fever,  376; 
Malaria,  381;  Rabies  or  Hydropliobia,  382;  Venereal  Dis- 
eases, 384;   Meningitis,  387 

Appendix 389 

Schedule    for    Sanitary    Survey    of   Cities,    389 ;    School- 
houses,    397 ;    Inspection    Schedule    Rtdating    to    Hospitals, 
399;   Sanitary  Inspection  of  Dairies,  402. 
Index 407 


ILLUSTRATIONS. 

FIGURE  PAGE 

1.  Generators  for  disinfection  with   solid  formaldehyd 60 

2.  The  simulium  fly  and  larva 172 

3.  Male  and  female  hookworms 188 

4.  Greatly  enlarged  view  of  hookworm  after  being  hatched   ....    188 

5.  Figure  of  worm  about  seven   days  old 188 

6.  Hookworm  eggs,  enormously  enlarged,  in  different  stages    ....    192 

7.  Bedbug   (Cimex  lectularius)  ;   Adult  female,  gorged  with  blood   .      .    196 

8.  Bedbug   (Cimex  lectularius)  ;  Egg  and  newly  hatched  larva   .      .      .    196 

9.  Bedbug   (Cimex  lectularius)  ;  Greatly  enlarged 196 

10.  The   Minnequa    Window    Curtain 250 

11.  Simple  wooden  holder  for  curtain  rods 250 

12.  Patients   on   crutches   ascending   incline 252 

13.  Man  ascending  fourteen-inch  step;  child  a  seven-inch  step  ....   252 

14.  Man  ascending  steps  on  crutches 252 

15.  Plan  of  inexpensive  eight-room   school        ...  254 

16.  Method   of  baiting   guillotine   trap       .      .      ' 274 

17.  Barrel   traps 274 

18.  Pit  trap 275 

19.  The  Poliomyelitis  Fly 280 

20.  One  of  the  Typhoid  Flies 281 

21.  Wire  gauze  fly  traps 284 

22.  Anopheles   mosquito;    adult   female 287 

23.  Resting  position  of  Anopheles  and  Culex  mosquitoes 287 

24.  How  not  to  build  a  privy 293 

25.  Note  the   danger   to  water   supply   and  the  possibilities   of   fly   and 

mosquito  infection  from  this  and  the  preceding  examples   .      .      .   294 

26.  A  sanitary  privy,  designed  to  prevent  soil  pollution 296 

27.  A  sanitary  privy,  designed  to  prevent  spread  of  disease   ....   297 

28.  A   single-seated   sanitary   privy    (Front  view) 298 

29.  Rear  and  side  view  of  privy  shown  in  Fig.  28 299 

30.  Six-seated  sanitary  privy  for  hotels  and  schools   (Front  view)    .      .   304 

31.  Rear  view  of  privy  shown  in  Fig.  30 305 

32.  Cement  septic  tank 309 

33.  Sanitary    cow    barn 330 


ILLUSTRATIONS. 
FIGURE  •  PAGE 

34.  Immaculate   milking    conditions 331 

35.  Babcock   butter   fat   tester 338 

36.  An  unsuspected  but  dangerous  tubercular  cow 342 

37.  Sanitary  milk  pails 343 

38.  .Surface    contamination 352 

39.  Contamination   by  jjercolation 352 

40.  Contamination    through    crevices 352 

41.  This  open  ditch   is  full  of  sewage  and  menaces  all  nearby  private 

water   supplies 355 

42.  A  sanitary  crime 355 

43.  An   effective  method   of   polluting  the  water   supply 356 

44.  Showing  location   of  privies   and   cesspools 357 

45.  Showing  distribution  of  contaminated  wells 357 

46.  Outdoor     incinerator         364 


INTRODUCTION. 

By  J,  N.  HuRTY,  M.D. 
Health  Commissioner,  State  of  Indiana. 

Public  and  personal  health  are  certainly  prominent  in  the  public 
mind  to-day,  and  they  well  may  be.  It  is  plain  that  the  future 
belongs  to  the  nation  which  has  the  greatest  proportion  of  healthy, 
strong  citizens;  hence,  the  national  and  State  governments  are 
deeply  interested  in  preserving  and  improving  the  public  health. 
The  individual  also,  is  now  keenly  alive  to  the  fact  that  only 
through  health  may  efficiency  with  success  be  attained;  therefore, 
he  too,  is  deeply  interested. 

Hygiene  is  the  science,  through  the  practical  application  of_ 
which  public  and  personal  health  may  be  _secnred,  and  all  eyes 
are  turned  toward  hygiene.  Sanitary  science  is  a  branch  or  depart- 
ment of  hygiene.  Its  part  is  to  secure,  in  a  thorough  and  eco- 
nomical manner,  ventilation,  water  supply,  sewage  disposal,  drain- 
age, waste  disposal,  and  all  the  conditions  which  hygiene  requires 
for  health.  Personal  hygiene  teaches  the  care  of  the  body  which 
is  necessary  in  order  to  keep  well  and  to  strengthen  the  constitu- 
tion. It  has  been  found  through  experience  that  it  is  not  enough 
simply  to  teach  hygiene,  but  in  some  degree  it  must  be  forced ;  and 
therefore,  laws  requiring  hygienic  conditions  are  necessary  and 
have  been  enacted  in  all  advanced  States.  The  more  progressive 
States  have  very  comprehensive  laws  which  relate  to  every  phase  of 
public  health  protection,  and  make  liberal  appropriations  for  their 
execution  and  enforcement.  Such  States  are  reaping  the  good 
fruits  of  their  wisdom. 

The  United  States  Public  Health  Service  is  doing  a  great  work 
in  the  cause  of  public  health  throughout  the  country.  Already,  in 
quite  all  the  States,  it  has  been  active  in  the  matter  of  applied 
hygiene.  In  California  and  the  other  Pacific  Coast  States,  it  has 
strangled  and  put  out  bubonic  plague;  in  Washington  and  other 
States  it  has  successfully  combated  typhoid  fever;  it  has  fought 
off  yellow  fever  from  the  Gulf  States ;  it  has  done  and  is  now  doing 


INTRODUCTION. 

a  mighty  service  against  hookworm  and  trachoma  in  the  Southern 
States.  In  a  sense,  it  may  be  truly  said  that  hygiene  is  building 
the  Panama  Canal ;  for  it  is  certain  that  had  she  not  been  evoked  to 
fight  yellow  fever  and  other  diseases,  the  United  States  would  have 
been  driven  away  as  was  France  in  her  day.  A  list  of  the  States 
would  be  long,  which  are  now  through  efficient  Boards  of  Health 
conducting  successful  campaigns  for  the  public  health. 

Consumption  is  slowly  retreating  before  the  onslaught  of  hy- 
giene, and  diphtheria  and  typhoid  fever  are  in  rapid  retreat. 
Smallpox  has  been  reduced  to  an  almost  negligible  quajitity,  and 
the  attack  of  hygiene,  through  medical  inspection  of  school  children, 
upon  the  defects  and  ills  which  beset  them,  will,  without  donbt, 
bring  large  returns  in  health  and  efficiency. 

The  foundation  of  all  intelligent  hygienic  work  is  vital  statistics. 
Vital  statistics — -the  bookkeeping  of  humanity— furnish  the  only 
means  of  knowing  the  whereabouts  of  disease  and  the  extent  of 
the  losses  caused  by  it.  They  also  tell  our  social  latitude  and 
longitude  on  the  sea  of  time,  which  the  nation  must  know  if  it  is 
to  endure.  From  these  facts  we  learn  that  we  must  know  the  loca- 
tion and  the  strength  of  the  enemy — Disease,  before  we  can  hope 
to  combat  it  successfully.  The  first  step  for  the  successful  conduct 
of  a  movement  for  the  betterment  of  the  public  health  is  the  col- 
lection of  correct  vital  statistics,  and  therefore  let  every  person 
do  his  part  and  see  to  it  that  the  births,  deaths  and  contagious 
diseases  which  occur  in  his  family  are  reported. 

This  book  treats  of  public  and  personal  hygiene,  entering  into 
details  and  discussing  their  many  features.  Its  teachings  are 
true  and  to  date,  and  it  may  be  confidently  stated  that  if  its  direc- 
tions and  lessons  are  heeded,  the  efficiency,  wealth  and  happiness 
of  the  commonwealth  will  be  greatly  augmented. 


PRACTICAL  SANITATION. 


PART  I. 
EPIDEMIOLOGY. 


Foreword. 


Epidemiology  is  that  phase  of  sanitary  science  which  treats  of 
the  causation,  symptoms,  and  methods  of  prevention  of  the  epi- 
demic and  endemic  infectious  diseases.  It  searches  for  the  mode 
of  transmission  of  disease,  and  endeavors  to  break  the  link  between 
the  present  case  and  any  possible  future  case.  To  do  this  it  em- 
ploys quarantine  (absolute  or  modified),  inspection  of  suspects, 
vaccination,  laboratory  diagnostic  methods,  clinical  observation, 
\    and  disinfection. 

Different  epidemiologists  differ  in  their  estimates  of  the  value 
of  the  various  sanitary  measures,  and  the  necessary  means  em- 
ployed may  differ  in  the  hands  of  the  same  man  with  time  and 
place.  Since  this  book  is  written  largely  for  the  busy  practitioner, 
who  for  the  public  good  gives  his  time  to  the  work  of  sanitation, 
and  wbo  has  neither  the  time  nor  the  opportunity  to  weigh  the 
relative  merits  of  different  measures  in  times  of  epidemic,  the 
means  herein  recommended  will  be  those  that  are  found  safest 
and  so  far  as  possible  are  simplified  so  that  the  lay  health  officer 
or  school  official  may  understand.  While  the  text  is  condensed, 
it  is  intended  to  be  full  enough  to  contain  the  essentials  of  diag- 
nosis and  the  needful  steps  to  be  taken  on  the  discovery  of  an 
epidemic  or  infectious  disease. 

It  must  be  understood  that  the  classification  employed  is  in  no 
,/  sense  based  on  pathology,  and  only  to  a  limited  extent  on  etiology ; 
the  only  factors  entering  into  it  being  the  avenues  of  infection 
and  the  methods  of  prevention. 

Such  a  classification  appears  somewhat  unnatural  when  viewed 

17 


18  PRACTICAL   SANITATION. 

from  the  standpoint  of  pathologj^  or  medical  practice,  but  should 
be  an  aid  to  the  sanitarian  in  clarifying  his  views  of  the  modes  of 
infection.  It  is  also  to  be  understood  that  such  an  arrangement 
must  be  purely  tentative,  since  advancing  knowledge  will  compel 
transfers  from  one  class  to  another,  but  for  the  present  it  is  probably 
as  good  as  any  other. 


CHAPTER  I. 
INFECTIOUS  PROCESSES. 

THE  NATURE  OF  INFECTION. 

Infectious  processes  are  ahvays  the  result  of  the  growth  and 
multiplication  of  some  definite  living  organism.  This  infective 
agent  may  be  bacterial,  as  in  diphtheria  and  typhoid  fever ;  proto- 
zoal, as  in  malaria  and  sleeping  sickness;  or  of  unknown  nature, 
as  in  smallpox  and  a  constantly  diminishing  group  of  diseases. 
Other  higher  groups  of  animal  and  vegetable  organisms  may  also 
be  of  importance  to  the  sanitarian,  as  the  well-known  hookworm 
and  ray-fungus,  but  for  the  purposes  of  this  chapter  will  not  be 
considered.  Every  case  of  infectious  disease  is  connected  with  a 
previous  case,  and  unless  the  chain  is  broken  by  proper  precau- 
tions, vnll  be  connected  with  a  series  of  later  cases.  Infection 
never  has  been  observed  to  arise  de  novo.  A  short  resume  of  the 
sources  of  infection  and  its  modes  of  transmission  follows : 

SOURCES  OF  INFECTION. 

Outside  the  Body. — The  number  of  diseases  whose  virus  is 
enabled  to  exist  outside  the  body  of  a  living  host  for  more  than  a 
short  time  is  small.  Such  germs  are  subjected  to  the  effects  of 
heat  and  cold,  of  desiccation,  and  especially  of  light,  which  is  fatal 
to  bacterial  life  (except  the  spores)  within  a  few  hours  at  most, 
provided  that  the  layer  containing  them  is  sufficiently  thin  to 
allow  the  light  to  penetrate  to  the  bottom.  Of  course,  this  state- 
ment does  not  apply  to  laboratory  cultures,  which  are  artificially 
placed  in  conditions  simulating  as  closely  as  possible  those  within 
the  body  of  the  host.  The  two  organisms  best  able  to  support  an 
indefinite  existence  outside  the  body  of  a  host  are  anthrax  and 
tetanus,  both  of  which  are  spore-bearing.  Typhoid  bacilli,  the 
spirilla  of  cholera,  the  germs  of  both  bacillary  and  amebic  dysen- 
tery, and  possibly  the  cocci  of  Malta  fever  are  able  to  support  a 
precarious  existence  outside  the  body,  usually  decreasing  rapidly 

19 


20  PRACTICAL  SANITATION. 

in  number  and  virulence,  owing  to  overgrowth  by  saprophytic 
organisms,  as  well  as  the  causes  named  above. 

Carriers  and  Missed  Cases. — In  overlooked  mild  cases  of  disease 
and  in  carriers  we  find  in  all  probability  the  explanation  of  most 
outbreaks  of  epidemic  disorders.  "We  know  beyond  peradventure 
that  typhoid  fever,  Asiatic  cholera,  diphtheria,  malaria  and  other 
diseases  whose  exciting  cause  is  capable  of  exact  demonstration 
are  carried  about  by  recovered  cases  and  people  who  are  not  known 
ever  to  have  had  the  disease.  Sanitarians  who  have  had  experi- 
ence in  fighting  scarlet  fever,  smallpox  and  measles  know  that 
their  hardest  problem  is  to  search  out  and  isolate  the  mild,  scarcely 
recognizable  cases.  It  is  at  least  worthy  of  thought  that  these 
diseases  of  unknown  etiology  may  have  carriers  in  good  health  as 
do  the  diseases  whose  etiology  is  known.  No  successful  anti-epi- 
demic work  can  be  done  that  fails  to  take  into  account  carriers  and 
mild  cases.  It  must  not  be  forgotten  that  carriers  may  give  off 
the  germs  intermittently,  as  is  surely  the  case  in  typhoid  fever. 
This  feature  also  puts  limits  to  the  value  of  isolation,  and  makes 
strict  isolation  early  in  an  epidemic  much  more  valuable  than  later. 

Contact. — This  may  be  immediate  or  mediate.  Immediate  con- 
tact is  the  direct  touching  of  the  sick  and  the  well,  with  transfer- 
ence of  the  disease  germs  to  the  latter.  Mediate  contact  presupposes 
a  person  or  an  object  interposed  between  the  sick  and  the  well. 
If  a  surgeon  contracts  erysipelas  from  an  operation  wound,  it  is 
immediate  contagion;  if  by  his  hands  or  instruments  another  per- 
son is  infected,  it  is  mediate  contagion.  Chapin  justly  states  that 
it  is  the  most  obvious  method  of  transmitting  disease.  But  it  is 
to  be  remembered  that  the  obvious  is  not  always  the  true  explana- 
tion, and  that  more  accurate  knowledge  may  compel  a  revision  of 
the  diseases  now  placed  here.  For  instance,  fifteen  years  ago 
yellow  fever  would  without  hesitation  have  been  placed  in  this 
class,  yet  it  is  now  definitely  known  to  have  a  secondary  life  cycle 
in  the  mosquito  and  never  to  be  contagious,  A  more  modern  in- 
stance is  typhus  fever  which  is,  according  to  accumulating  evidence, 
only  transmitted  through  the  body  louse.  On  the  other  hand, 
typhoid,  which  was  only  a  few  years  ago  thought  to  be  almost 
wholly  water-borne,  is  now  known  to  be  in  a  great  proportion  of 
cases  contracted  through  contact. 

Fomites. — This  form  of  infection  is  like  that  of  mediate  con- 
tact, with  the  exception  that  a  greater  period  of  time  is  supposed 


INFECTIOUS  PROCESSES.  21 

to  elapse  between  the  infection  of  the  fomites  and  its  transmission 
to  the  person  infected.  Only  a  few  years  ago  it  was  supposed  to 
be  one  of  the  most  important  modes  of  infection,  but  modem 
methods  have  narrowed  and  restricted  its  importance  until  at 
present  only  a  very  few  diseases,  such  as  smallpox,  scarlet  fever, 
typhoid  fever  and  a  few  others  are  believed  to  be  possibly  trans- 
missible in  this  way,  and  these  but  rarely.  Tetanus  and  anthrax, 
having  spore-bearing  bacilli  as  their  cause,  are  not  at  all  infre- 
quently communicated  by  fomites ;  but  non-spore-bearing  organisms 
are  rapidly  killed  by  adverse  influences,  or  lose  their  virulence,  or 
are  not  present  at  any  time  in  sufficient  numbers  to  have  any 
effect.  In  the  future,  fomites  will  occupy  the  attention  of  the 
sanitarian  less  and  less,  and  greater  attention  will  be  given  to 
other  modes  by  which  infection  may  be  transmitted. 

Air. — Aerial  transmission  of  disease  has  for  long  been  an  estab- 
lished dogma  in  the  eyes  of  the  laity  and  a  large  part  of  the  medical 
profession,  yet  the  evidence  for  an  aerial  convection  of  disease 
except  in  dust  or  in  droplets  of  saliva  or  bronchial  secretion 
coughed  out  by  the  sick,  is  nil.  A  number  of  germs,  notably  those 
of  typhoid  fever,  dysentery,  iVIalta  fever,  tuberculosis,  anthrax, 
and  the  pus  organisms  may  be  conveyed  in  dust,  and  any  of  the 
infections  in  which  the  mouth  and  throat  are  involved  as  diph- 
theria, tuberculosis,  pneumonia,  influenza  and  others  are  known 
to  be  conveyed  by  the  droplets  expelled  from  the  mouth  in  sneezing, 
coughing,  and  speaking.  This  is  very  certainly  (although  the 
assertion  cannot  be  proved)  the  ordinary  method  for  the  communi- 
cation of  measles,  scarlet  fever  and  the  other  exanthemata,  includ- 
ing smallpox. 

Water. — ^This  is  a  very  common  medium  for  the  transmission  of 
typhoid,  cholera,  and  dysentery  of  both  types ;  and  there  is  a  certain 
amount  of  evidence  that  sewage  infected  water  may  contribute  to 
swell  the  incidence  of  tuberculosis.  It  may  be  infected  at  the 
source  or  at  any  other  place  where  it  is  handled  or  stored  before 
it  reaches  the  consumer.  There  is  a  tendency  for  the  water- 
bacteria,  the  action  of  light,  and  sedimentation,  to  kill  out  patho- 
genic bacteria;  but  a  point  is  quickly  reached  beyond  which  these 
agencies  cannot  go,  if  the  influx  of  infected  material  is  large,  and 
especially  if  it  is  accompanied  by  large  quantities  of  sewage  or 
other  organic  matter.  Improvement  in  the  purity  of  a  water  sup- 
ply is  always  accompanied  'pari  passu  by  improvement  in  the  public 


22  PEACTICAL  S^VNITATION. 

healiJi.  In  the  tropics,  where  Americans  drink  boiled  water  quite 
as  a  matter  of  course,  they  are  much  more  free  from  the  above 
named  diseases  than  the  natives  who  drink  raw  water,  although 
almost  all  of  the  preparation  of  food  and  drink  is  done  by  natives. 
The  sanitarian  finds  as  his  first  duty  that  he  must  secure  a  water 
supply  free  from  contamination,  or  failing  that,  must  educate  the 
people  to  boil,  adequately  filter  or  otherwise  sterilize  the  water 
they  use,  and  money  spent  to  this  end  is  wisely  employed. 

Food. — The  diseases  noted  as  water-borne  are  also  food-borne 
and  in  addition  diphtheria,  scarlet  fever  and  possibly  other  infec- 
tions are  transmitted  in  food — especially  in  milk.  The  infection 
of  milk  is  almost  always  secondary,  occurring  after  it  has  been 
drawn  from  the  cow.  Diphtheria  of  the  cow's  udder  has  been 
definitely  proved  in  two  instances  to  cause  epidemics,  and  the  milk 
of  infected  goats  is  the  normal  source  of  infection  for  Malta  fever. 
Bovine  tuberculosis  is  also  transmitted  to  man  through  the  medium 
of  milk,  but  in  all  probability  more  rarely  than  is  usually  believed. ) 
Diarrheal  diseases,  though  of  uncertain  bacteriology,  are  often 
conununicated  through  the  milk  supply,  the  infection  occurring 
after  the  milk  is  drawn. 

Insects. — The  list  of  diseases  known  to  be  transmitted  by  insects 
is  growing  large  and  is  ordinarily  fairly  easy  to  handle  from  a 
sanitary  standpoint,  for  the  reason  that  insects  can  be  seen  and 
sought  out  and  by  proper  methods  destroyed  wholesale.  To  enu- 
merate :  Malaria  is  carried  by  the  Anopheles  mosquito ;  yellow 
fever  by  the  Stegomyia ;  dengue  and  filariasis  by  the  Culex ;  Rocky 
Mountain  fever  and  African  relapsing  fever  by  ticks;  typhus  and 
European  relapsing  fever  by  the  louse  and  perhaps  the  bedbug; 
sleeping  sickness  by  the  tsetse  fly;  and  kala-azar  by  the  bedbug^ 
This  list  is  likely  to  be  added  to  rather  than  diminished,  and  in 
the  instances  named  there  is  no  other  known  mode  of  infection. 
The  flea  is  the  ordinary  agent  for  the  dissemination  of  plague,  al- 
though contact  infection  is  responsible  for  the  pneumonic  form, 
(^lies,  as  noted  in  the  special  chapter  devoted  to  them,  are  respon- 
sible for  much  infection — especially  in  places  where  garbage  and 
\  night  soil  are  badly  handled) 

Dosage. — The  idea  of  dosage  of  infection  is  familiar  to  the  bac- 
teriologist, but  less  so  to  the  man  without  laboratory  experience. 
In  working  with  pure  cultures  of  known  bacteria  it  has  been  found 
that  in  order  to  kill  animals  of  a  certain  species  and  weight,  a 


INFECTIOUS  PKOCESSES.  23 

certain  minimum  number  of  bacteria  must  be  employed.  It  has 
also  been  found  that  almost  all  bacteria  differ  in  virulence  accord- 
ing to  the  source  from  which  drawn  and  the  method  of  cultivation. 
These  two  facts  enable  us  to  understand  the  occurrence  of  carriers 
and  unrecognized  cases  of  the  infectious  diseases,  the  explanation 
being  either  that  the  dosage  has  been  insufficient  to  cause  severe 
illness  or  the  virulence  too  low  to  affect  that  particular  person. 
Changed  conditions  causing  lowered  resistance  on  the  part  of  the 
host  or  an  increase  in  numbers  or  virulence  on  the  part  of  the 
germ  may  convert  a  non-immune  carrier  into  an  active  case,  while 
other  changes  may  kill  out  the  organism  and  leave  the  host  normal. 

Great  as  have  been  the  advances  made  in  the  last  generation, 
only  a  beginning  has  been  made  in  the  study  of  the  infections. 
In  the  future  development  of  epidemiology,  the  local  health  officer 
who  sees  his  cases  in  scattered  communities  where  infection  is 
more  easily  traced,  must  have  an  important  part.  By  consultation 
^^dtll  the  highly  trained  men  in  the  offices  and  laboratories  of  the 
State  Boards  of  Health,  and  by  careful  searching  out  and  study  of 
the  problems  presented  to  him,  he  may  be  able  to  throw  light  on 
difficult  and  apparently  insoluble  problems.  He  should  not  forget 
that  careful  clinical  observation  is  a  guide  and  check  to  laboratory 
work,  and  should  lose  no  opportunity  to  inform  himself  on  this 
most  difficult  subject.  Routine  work  done  in  a  routine  way  will 
prove  of  no  value  to  science,  however  valuable  it  may  be  practically 
to  the  community. 


CHAPTER  II. 

THE  MANAGEMENT  OF  EPIDEMICS. 

Definition. — Epidemic  is  a  term  rather  loosely  applied  to  an 
unusual  prevalence  of  any  infectious  disease.  Strictly  endemic 
diseases,  such  as  tuberculosis,  may  present  in  a  community  at  any 
time  a  number  of  victims  which  would  greatly  alarm  the  public  if, 
for  instance,  smallpox  or  cerebrospinal  meningitis — not  to  men- 
tion Asiatic  cholera  or  bubonic  plague — were  present  in  the  same 
degree,  and  any  one  of  which  would  certainly  be  said  to  be  in  epi- 
demic form. 

General  Principles. — The  best  way  to  manage  epidemics  is  to 
avoid  them  and  this  is  preeminently  the  aim  of  the  sanitarian. 
That  is  to  say,  that  with  the  first  sporadic  cases  of  any  dangerous 
disease,  immediately  on  the  determination  of  their  character,  the 
health  officer  must  with  the  utmost  promptness  quarantine  and 
trace  out  all  sick,  contacts,  and  suspects,  a]id  carry  out  with  them 
the  appropriate  measures  of  isolation,  immunization,  and  disinfec- 
tion. Energetically  handled  a  situation  often  loses  its  threatening 
aspect  almost  at  once.  Publicity  is  a  great  weapon  in  such  cases. 
The  public  will  make  light  of  the  trouble  in  another  place,  but  as 
soon  as  the  dreaded  disease  appears  at  home  it  is  usually  willing 
to  cooperate,  provided  it  is  thoroughly  convinced  that  the  danger 
is  real.  Publicity  should  not,  however,  go  to  the  length  of  creating 
panic.  It  is  always  better  to  lay  the  emphasis  on  the  means  of 
defense  against  disease  than  on  the  danger.  The  average  man 
has  sufficient  fear  in  the  presence  of  an  epidemic  to  make  him 
exaggerate  the  risk  beyond  the  actual. 

If  appropriations  are  to  be  asked  from  lay  Boards  of  Health  or 
City  Councils,  it  is  well  to  state  frankly  the  worst  of  the  dangers, 
and  this  is  also  necessary  if  the  general  public  for  any  reason  is 
indifferent  to  consequences  and  refuses  to  take  the  necessary  meas- 
ures to  insure  safety. 

Established  Epidemics. — Suppose  the  means  above  mentioned 
have  failed?     What  measures  are  next  to  be  adopted?  /  The  first 

24 


THE    MANAGEMENT    OP   EPIDEMICS.  25 

thing  for  the  health  officer  to  do  is  to  arrange  to  give  his  entire 
time  and  attention  to  suppressing  the  disease,  ^Tlie  second  is  to 
go  to  the  treasurer  in  charge  of  the  sanitary  funds  and  ascertain 
how  much  of  a  balance  is  available  for  the  work  in  hand.  The 
-^third  is  to  determine  the  amount  which  will  probably  be  needed 
and  secure  an  appropriation  for  the  deficiency  from  the  proper 
authorities.  In  arriving  at  this  estimate  he  should  ask  himself 
what  professional  assistance  will  be  needed  for  house  and  school 
inspection;  for  lay  assistance;  for  disinfection;  for  rent  or  pur- 
chase of  suitable  quarters  for  a  hospital  and  for  subsistence  and 
running  expenses  of  the  same;  for  nursing;  for  vehicles  for  in- 
spectors and  transporting  patients,  and  so  on.  If  the  sum  at  his 
disposal  is  not  sufficient  for  all  these  purposes,  the  health  officer 
should  determine  which  are  least  essential  under  the  circum- 
stances. 

Maps. — Every  health  officer  should  be  provided  with  a  blueprint 
map  of  his  territory  on  as  large  a  scale  as  possible.  No  general 
would  undertake  a  campaign  without  maps  of  the  country  in 
which  he  was  to  fight,  and  no  health  officer  ought  to  undertake  a 
campaign  against  disease  without  the  same  aid.  "Without  it  he 
cannot  keep  in  mind  the  location  of  the  various  cases — especially 
with  regard  to  their  contiguity  to  churches,  public  halls,  and 
schools.  Colored  pins,  which  may  be  bought  in  any  dry  goods 
store,  are  used  for  the  record,  thus :  yellow,  suspects  and  contacts ; 
red,  sick ;  white,  recovered  and  disinfected ;  black,  died.  Small 
numbered  and  dated  paper  flags  may  be  used  on  the  pins,  and 
when  the  epidemic  is  over  the  whole  history  may  be  read  from  the 
map. 

Maps  also  facilitate  inspection  work,  as  it  is  easy  to  assign 
inspectors  to  definite  districts  and  hold  them  responsible  for  work 
done.  For  this  use,  pins  with  inspectors'  letter  or  number  and 
the  date  fix  the  time  of  inspectors'  visits. 

Another  most  useful  adjunct  to  this  kind  of  work  is  a  skeleton 
showing  4  blocks,  with  intervening  streets  and  alleys,  on  a  scale 
of  2  inches  to  the  block.  The  inspector  fills  this  in  with  the  detail, 
drawing  in  freehand  the  location  of  infected  houses,  nuisances 
and  the  like,  and  adding  on  the  wide  margin  any  explanatory 
notes.  Such  sketch-maps  enable  the  health  officer  at  once  to  under- 
stand the  situation  reported  and  to  file  the  report  for  record  with- 
out trouble. 


26  PRACTICAL   SANITATION. 

Medical  Inspectors. — The  duties  of  medical  inspectors  are :  first, 
the  examination  of  suspicious  cases  where  no  physician  has  been 
called,  or  if  there  is  reason  to  believe  that  he  has  made  a  mistake 
or  is  wilfully  concealing  the  disease;  second,  for  vaccination  or 
immunization  of  contacts;  third,  for  the  examination  of  contacts 
and  convalescents  prior  to  disinfection;  fourth,  for  the  inspection 
of  school  children.  Kegarding  the  first  item,  the  health  officer  or 
his  medical  deputies  should  not  intervene  between  patient  and 
attending  physician  except  on  the  strongest  grounds  or  in  great 
emergencies.  The  value  and  necessity  of  the  next  two  heads  are 
self  evident,  but  that  of  the  last  is  not  so  apparent. 

In  epidemics  of  diphtheria,  measles  and  scarlet  fever,  it  is  better 
to  have  the  children  in  a  properly  ventilated  school  house  under 
daily  inspection,  than  to  have  them  running  everywhere,  uncon- 
trolled. It  may  be  necessary  to  stop  picture  shows,  and  Sunday 
schools  or  similar  gatherings,  but  the  opportunity  to  keep  them 
under  surveillance  in  the  schools  is  one  not  lightly  to  be  thrown 
away.  This,  however,  does  not  apply  to  rural  schools  in  thinly 
settled  districts,  where  medical  inspection  is  not  possible  and  there 
is  not  much  chance  for  the  children  to  congregate. 

Lay  Inspectors. — Lay  inspectors  should  have  police  powers,  and 
may  be  detailed  to  look  after  quarantines,  inspect  for  nuisances 
and  see  that  they  are  abated,  and  after  proper  instruction,  do 
disinfecting.  Former  soldiers,  naval  seamen,  and  marines  make 
the  best  lay  inspectors,  as  they  are  trained  in  hygiene  and  are 
accustomed  to  obey  orders. 

Special  Hospitals. — The  question  of  contagious  disease  hospitals 
is  a  difficult  one  in  the  small  city  or  town  for  the  reason  that 
ordinarily  no  regular  hospital  of  this  kind  is  available  and  one 
must  be  improvised.  If  there  is  reason  to  expect  an  epidemic  of 
any  size  of  smallpox,  cholera,  yellow  fever,  typhus  or  plague,  a 
special  hospital  should  be  at  once  instituted,  as  the  expense  and 
danger  to  the  community  are  at  once  minimized.  Some  states  give 
the  health  authorities  power  to  seize  property  for  this  purpose, 
but  in  any  ease  it  is  better  to  negotiate  for  the  necessary  site  and 
buildingrs.  The  organization  and  maintenance  of  isolation  camps 
and  hos[)itals  will  be  treated  at  length  in  a  special  chapter. 

School  Inspection. — As  mentioned  earlier  in  this  chapter,  school 
inspection  is  of  the  greatest  value  wherever  it  is  possible  to  use  it. 
In  diphtheria,  smears  should  be  made  from  the  mouth  and  nose 


THE    MANAGEMENT    OF   EPIDEMICS.  '         27 

to  locate  carriers  who  might  otherwise  escape  detection.  Scarlet 
fever  and  measles  are  detected  in  their  incipiency.  At  these  times 
any  children  who  for  any  reason  are  out  of  school  should  be  visited 
by  a  medical  inspector,  and  if  not  seen  by  any  physician,  he  should 
examine  them.  No  child  should  be  permitted  to  re-enter  school 
without  a  "clearance  slip"  from  the  health  officer  or  a  medical 
inspector,  and  the  school  authorities  should  daily  receive  from  the 
health  officer  slips  showing  which  children  are  excluded  from  school 
on  account  of  disease  and  which  are  permitted  to  return.  Forms 
for  this  purpcse  are  shown  and  described  in  Chapter  XXVI. 
(School  Inspection.) 

Nurses. — The  expense  of  nurses  may  be  thrown  on  the  munici- 
pality, and  it  is  for  the  health  officer  to  determine  whether  he  will 
concentrate  all  his  nurses  in  the  isolation  hospital  or  will  divide 
his  force  in  private  houses.  The  former  method  is  much  more 
efficient — especially  with  a  small  force.  Trained  nurses  may  also 
be  used  to  advantage  as  quarantine  inspectors  and  instructors  of 
volunteer  nurses  in  private  families. 

Notification. — By  statute  and  by  the  rules  of  the  various  boards, 
certain  of  the  infectious  diseases  usually  characterized  in  the 
statutes  as  "dangerous"  are  required  to  be  reported  within  a 
certain  period  (usually  24  hours  or  less)  to  the  local  health  office, 
in  order  that  the  proper  action  may  be  taken.  This  law  is  binding 
on  householders  and  freeholders  as  well  as  on  physicians,  and  the 
same  penalties  are  prescribed  for  failure  so  to  report.  The  form 
of  this  report  and  the  records  based  thereon,  as  well  as  its  final 
disposition,  will  be  discussed  in  the  chapter  on  Statistical  Methods. 

It  is  also  made  the  duty  of  the  health  officer,  on  hearing  from 
any  source  of  a  suspicious  case,  to  investigate  and  satisfy  himself 
as  to  its  nature.  It  is  good  practice  in  order  to  make  the  report- 
ing as  easy  as  possible  for  physicians  and  the  public,  to  accept 
telephonic  reports  and  fill  out  the  notification  slips  in  the  office, 
marking  them  "telephonic"  to  show  the  source  of  the  information. 

Plural  Infections. 

Inexperienced  health  officers  are  often  skeptical  as  to  the  occur- 
rence of  two  infectious  diseases  in  the  same  individual  at  the  same 
time.  The  following  figures  from  the  Kingston  Avenue  Hospital, 
New  York,  for  1908  are  most  instructive  in  this  regard,  and  warn 
the  health  officer  that  if  two  or  more  epidemics  are  present  in  his 


28  PRACTICAL   SANITATION. 

territory,  lie  must  be  on  the  lookout  for  instances  of  plural  infec- 
tion : 

Diphtheria  and  scarlet  fever 44 

Diphtheria  and  measles 19 

Diphtheria  and  varicella  i 3 

Diphtheria  and  pertussis 1 

Scarlet  fever  and  measles 41 

Scarlet  fever  and  varicella " 8 

Scarlet  fever  and  pertussis 2 

Scarlet  fever,  measles,  and  varicella 1 

Measles  and  pertussis 6 

Measles  and  varicella 5 

Total    130 

This  gives  an  incidence  of  multiple  or  plural  infections  of  130 
out  of  2,887  cases  treated — a  percentage  of  nearly  4.5 — much 
higher  than  would  be  likely  to  be  found  except  under  metropolitan 
conditions,  where  the  above-named  diseases  are  endemic. 

Reduction  of  Mortality  from  Infectious  Diseases. 

The  Eeport  of  the  Department  of  Health  for  the  City  of  New 
York  for  1908,  from  which  the  above  figures  are  quoted,  present 
a  most  interesting  summary  of  the  reduction  made  in  the  mortality 
from  infectious  diseases  during  the  preceding  three  decades.  It 
should  be  noted  that  this  Health  Department  is'  not  only  highly 
organized,  but  is  well  supplied  with  funds,  the  per  capita  appro- 
priation being  fifty  cents,  as  against  five  to  ten  cents  for  the  most 
of  the  country.  When  the  remainder  of  the  United  States  is  as 
well  organized  as  the  City  of  New  York,  and  as  well  provided  with 
funds,  the  same  results  are  to  be  expected  elsewhere. 

The  following  diseases  and  causes  of  death  are  those  which  have 
been  the  targets  against  which  the  bolts  of  sanitary  science  have 
been  hurled ;  with  what  effect,  the  following  comparisons,  based 
upon  the  previous  table,  will  show: 

1.  Typhus  Fever. — This  dreaded  disease  has  entirely  disappeared  from  the 
causes  of  death  since  the  years  of  its  importation,  1892  and  1893. 

2.  Asiatic  Cholera. — In  the  year  1849  this  disease  carried  off  5,071  inhab- 
itants of  the  city;  in  1854  there  were  2,509  deaths  reported,  and  in  186G — the 
year  of  the  organization  of  the  Board  of  Health — 1,137  deaths;  in  the  decen- 
nium,  1868-1877,  30  deaths;  in  that  of  1878-1887.  no  deaths;  in  that  of 
1888-1897,  9  deaths;  since  1892  the  city  has  not  suffered  the  loss  of  one 
inhabitant  from  this  cause. 


THE   MANAGEMENT   OF  EPIDEMICS.  29 

3.  Smallpox. — Out  of  every  100,000  of  the  population  48  died  in  the 
decennium  1868-1877,  7  in  that  of  1878-1887,  3  in  that  of  1888-1897,  and  2 
in  that  of  1907,  comparing  the  latter  decennium  with  that  of  1868-1877,  a 
reduction  of  95  per  cent. 

4.  Typhoid  Fever. — Tlie  rate  per  100,000  in  tlie  decennium  18G8-1877  was 
31,  and  in  the  subsequent  decennia  fell  to  28,  20  and  IS;  the  rate  fell  to  12 
in  1908,  a  decrease  of  61  per  cent,  compared  with  that  of  the  first  decennium, 
a  reduction  which  fell  far  short  of  the  actual  condition,  for  if  we  consider  the 
immense  strides  made  in  medical  diagnosis  as  to  this  disease,  we  can  not  but 
realize  that  in  earlier  decades  many  deaths  that  should  have  been  reported 
under  this  heading  found  place  under  indefinite  titles;  for  example,  under 
the  heading  of  typhoid  fever,  4,445  deaths  were  enumerated  in  the  first 
decennium,  and  3,626  under  that  of  malarial  fevers,  while  under  the  same  head- 
ings in  the  decennium  1898-1907  the  figures  were  6,349  and  1,112  respectively, 
the  ratio  of  typhoid  to  malarial  deaths  in  the  first  decennium  being  one  and 
one-quarter  deaths  to  one,  and  in  the  last  six  to  one;  undoubtedly  there  has 
been  an  immense  transference  from  the  malarial  death  column  to  that  of 
typhoid;  it  is  very  evident  that  the  deaths  from  malarial  fever  originating  in 
this  climate  are  seldom  fatal,  most  of  those  that  are  reported  being  probably 
of  a  pernicious  type  having  origin  in  southern  latitudes.  It  is  only  fair  to 
assujne  that  the  death  rates  from  typhoid  fever  in  remote  years  did  not  reflect 
the  true  index  of  mortality  from  this  disease.  If  we  add  the  number  of 
deaths  in  the  first  decennium  from  malarial  fevers  to  those  from  typhoid  fever 
the  result  is  a  total  of  8,071  deaths  with  a  rate  of  57  per  100,000  against  7,461 
deaths  and  a  rate  of  21  per  100,000  during  the  last  decennium,  a  decrease  of 
63  per  cent. 

5.  Malarial  Fevers. — In  the  decennium  1868-1877  the  rate  per  100,000  was 
26,  which  rose  to  30  in  the  succeeding  one,  then  fell  to  18,  and  finally  to  3  in 
the  last  decennium;  if  we  compare  the  latter  rate  with  the  first,  a  decrease  of 
almost  90  per  cent,  will  be  shown. 

6.  Measles. — The  mortality  from  this  cause  rose  from  28  in  the  ten  years 
1868-1877  to  37  in  the  next  decennium,  fell  to  31  in  the  next,  and  then  to  20 
in  the  last, 

7.  Scarlet  Fever. — The  decrease  in  the  mortality  from  this  cause  has  been 
a  tremendous  one,  reaching  78  per  cent.,  comparing  the  rates  of  the  decennium 
1898-1907  with  that  of  1868-1877;  the  number  of  deaths  in  the  latter  ten  years 
reached  12,978,  while  in  the  former  only  6,864  were  reported. 

8.  Diphthei-ia  and  Croup  gave  a  death  rate  of  153  per  100,000  in  the  decen- 
nium 1868-1877,  and  53  in  that  of  1898-1907,  a  decrease  of  66  per  cent.,  that 
is  where  three  children  died  from  this  cause  in  the  former,  only  one  died  in  the 
latter  decennium;  in  1894  the  rate  was  163  per  100,000;  in  1895— the  year 
of  the  introduction  of  diphtheria  antitoxin — the  rate  was  127,  and  in  the  fol- 
lQ,wing  year  fell  to  86,  since  which  year  it  has  not  reached  60,  and  in  1907  and 
1908  fell  to  40. 

9.  Whooping-Cough. — Under  this  head  5,212  deaths  and  a  rate  of  37  per 
100,000  were  recorded  in  the  decennium  1868-1877,  and  4,124  deaths  and  a  rate 
of  12  in  that  of  1898-1907,  a  decrease  of  68  per  cent.:  that  is,  three  children 
succumbed  from  this  disease  in  the  former  to  one  in  the  latter  decennium. 


30 


PRACTICAL   SANITATION. 


10.  Pulmonary  Tuberculosis. — There  were  5,374  deaths  reported  under  this 
heading  in  the  decennium  1868-1877,  with  a  mortality  of  376  dying  out  of 
every  100,000  of  the  population;  this  high  mortality  rate  fell  gradually  until 
in  the  decennium  1898-1907  it  reached  tlie  comparatively  low  figure  of  224, 
a  decrease  of  40  per  cent.  During  the  past  ten  years  the  number  of  deaths 
certified  from  this  cause  was  79,637. 

11.  Diarrhoeal  Diseases. — The  mortality  rate  of  30.3  per  1,000  children 
under  the  age  of  five  years  in  the  decennium  1808-1877  fell  to  23.4,  then  to 
19.7,  and  finally  to  13.5  during  the  subsequent  decennia.  The  rate  from  this 
cause  has  always  been  considered  a  reliable  standard  whereby  to  judge  the 
sanitary  conditions  of  a  locality,  and  from  the  above  decline  in  the  mortality — 
especially  when  the  following  facts  are  considered:  first,  the  extremely  high 
temperature  occurring  during  the  summer  months;  and  second,  the  high 
birth  rate  among  tlie  foreign-born  non-English-speaking  population  in  the 
community — it  is  fair  to  assume  that  the  efforts  of  this  department  supple- 
mented by  those  of  tlie  various  charitable  organizations  have  been  produc- 
tive of  this  encouraging  result. 

12.  Death  Rate  of  Children  Under  Five  Years  of  Age. — This  is  considered 
one  of  the  most  reliable  tests  of  the  sanitary  condition  of  a  community,  and  the 
following  short  table  shows  what  proportion  the  decrease  in  mortality  at  this 
group  of  ages  has  taken  place  in  the  present  Boroughs  of  Manhattan,  Brooklyn 
and  The  Bronx,  which  house  about  93  per  cent,  of  the  population  of  the  entire 
city : 


Decennium. 

Average    Number 

OF  Deaths 

Under  5  Years 

Decennial      Rate 
OF    Number    of 
Children  Un- 
der 5  Years. 

Per  Cent.  Reduc- 
tion OF  Previous 
Decennium. 

1878-1887    

21,653 
26,142 
23,305 
22,536 

97.8 
86.2 
57.9 
47.0 

1888-1897    

12 

1898-1907    

33 

1908     

18 

It  is  evident  that  this  decrease  in  the  mortality  at  this  age-group  has 
been  a  considerable  one,  greater,  in  fact,  than  at  any  other  age-group,  accord- 
ing to  tables  recently  compiled,  and  we  are  not  surprised  at  this  when  we  con- 
sider the  reduced  mortality  previously  spoken  of  in  discussing  the  rates  from 
individual  causes  of  death,  such  as  measles,  scarlet  fever,  diphtheria  and 
croup,  wliooping-cough,  diarrhoea,  and  to  a  limited  extent,  smallpox  and  tuber- 
culosis. 


Laws. — Having  discussed  the  means  to  be  employed  in  the  man- 
agement of  epidemic  diseases,  the  legal  grounds  on  which  action  is 
based  should  next  be  considered.  All  health  laws  spring  from 
the  police  power  of  the  state,  and  in  their  last  analysis  are  based 


THE   MANAGEMENT   OF   EPIDEMICS.  31 

on  the  inalienable  right  of  self-defense,  which  inheres  in  the  state 
as  in  the  individual.  Since  it  is  impossible  for  a  legislature  to 
foresee  every  contingency  which  may  arise,  the  health  statutes  of 
all  the  states  are  flexible,  delegating  to  the  State  Boards  and  to 
subordinate  boards  or  officers  the  authority  to  act  in  emergency 
as  they  deem  best  for  the  public  interest.  For  example,  the  Con- 
necticut statute  provides  that  boards  of  health  have  "all  the  powers 
necessary  and  proper  for  the  preservation  of  the  public  health  and 
the  prevention  of  the  spreading  of  malignant  diseases"  and  makes 
it  their  duty  to  ' '  examine  into  all  nuisances,  sources  of  filth  injuri- 
ous to  the  public  health,  and  cause  to  be  removed  all  filth  found 
within  the  town  which  in  their  judgment  shall  endanger  the  health 
of  the  inhabitants. ' '  This  act  has  been  held  to  give  express  power 
to  decide  what  is  filth,  and  that  no  redress  is  possible  for  an  error 
in  judgment.     (Raymond  vs.  Fish,  51  Conn.  80.) 

A  Massachusetts  decision  says  "The  board's  determination  of 
questions  of  discretion  and  judgment  in  the  discharge  of  its  duties 
is  in  the  nature  of  a  judicial  decision  and  within  the  scope  of  the 
powers  conferred,  and  for  the  purposes  for  which  the  determina- 
tion is  required  to  be  made  it  is  conclusive.  It  is  not  to  be  im- 
peached nor  set  aside  for  error  or  mistake  of  judgment,  nor  to  be 
reviewed  in  the  light  of  new  or  additional  facts.  The  officers  or 
board  to  whom  such  determination  is  confided,  and  all  those  em- 
ployed to  carry  it  into  effect  or  who  may  have  occasion  to  act  upon 
it,  are  protected  by  it  and  may  safely  rely  on  its  validity  for  their 
defense."     (Salem  vs.  Eastern  By.  Co.,  98  Mass.  431.) 

The  United  States  courts  also  have  taken  a  broad  view  of  the 
duties  of  the  sanitary  authorities,  as  shown  in  a  recent  decision  of 
the  court  for  the  Eastern  District  of  Louisiana,  in  a  case  where 
certain  property  owners  sought  to  defeat  the  enforcement  of  a  rat- 
prcofing  ordinance  recommended  by  the  Public  Health  Service 
and  adopted  by  the  City  of  New  Orleans.     The  decision  follows : 

Tlie  allegations  of  the  bill  in  this  case  held  to  sustain  the  jurisdiction  of 
the  United  States  court  on  the  gi-ound  that  the  case  is  one  arising  under 
the  Constitution   and  laws  of  the  United   States. 

A  municipality,  through  its  health  officers  and  other  proper  agents,  may 
enact  measures  for  the  safety  and  to  preserve  the  health  of  its  inhabitants, 
and  it  could  not  be  considered  unreasonable  of  itself  to  provide  for  the 
constrviction  of  buildings  according  to  certain  specifications  to  effect  that 
end.  And  it  is  not  unreasonable  of  itself  that  the  mechanical  work  be  done 
subject  to  the  approval  of  some  one  in  authority,  such  as  the  health  officer. 


32  PRACTICAL   SANITATION. 

as  some  one  must  necessarily  have  supervision  of  the  work  in  order  to  insure 
the  proper  observance  of  the  law. 

In  view  of  the  danger  to  the  community  from  plague  and  tlie  migratory 
habits  of  rats,  it  is  reasonable  to  make  rat-proofing  ordinances  apply  through- 
out a  city  instead  of  restricting  their  operation  to  limited  areas  around 
known   foci  of  infection. 

On  the  facts  presented  to  the  court  and  for  the  purposes  of  a  motion  for 
a  preliminary  injunction,  the  court  held  that  the  New  Orleans  ordinances 
requiring  rat  proofing  are  reasonable,  necessary,  and  appropriate. 

The  allegation  that  inspectors  charged  with  the  enforcement  of  ordinances 
are  overzealous,  arbitrary,  and  exceed  their  authority,  even  if  true,  does 
not  furnish  ground  for  an  injunction  stopping  the  entire  work  throughout 
the  city. 

The  fact  that  compliance  with  ordinances  requiring  the  rat  proofing  of 
buildings  will  work  hardship  to  the  owners  of  specific  property  is  not  suffi- 
cient cause  for  declaring  the  ordinances  null  and  inoperative,  as  in  matters 
affecting  the  health  of  the  entire  community  the  convenience  of  the  in- 
dividual must  yield  to  the  necessity  of  the  whole  people. 

(ilrs.    Wid.   John    G.   Kuhlman,    et   als.,   v.    Dr.    W.    C.   Rucker,    et   als. — 
No.  15207.     Mar.  .13,  1915.) 

The  tendency  of  the  courts  is  to  support  the  health  authorities, 
at  least  regarding  measures  found  necessary  in  epidemics,  pre- 
cisely as  they  protect  the  policeman  who  shoots  a  dangerous  crimi- 
nal who  is  resisting  arrest,  or  the  firemen  who  find  it  necessary  to 
blow  up  a  burning  building  to  protect  the  remainder  of  the  city. 

By  the  statutes  of  all  of  the  states,  the  health  authorities  are 
allowed  to  call  on  all  peace  officers  for  necessary  assistance  in  com- 
pelling the  observance  of  the  health  laws,  and  under  various  penal- 
ties this  help  must  be  provided,  so  that  no  health  officer  should 
confess  himself  helpless  until  he  has  exhausted  this  resource. 

But,  on  the  other  hand,  for  failure  to  do  his  own  full  duty  under 
such  circumstances,  he  is  liable  to  removal  from  office,  to  fine  or 
imprisonment,  or  all  three;  and  the  State  Board  of  Health  by  its 
agents  or  in  person  is  authorized  to  take  charge.  So  the  state 
protects  itself  against  the  derelict  municipality  as  the  city  or  town 
does  against  the  individual. 

The  law,  then,  being  what  it  is,  gives  every  incentive  to  the 
honest,  thorough  performance  of  duty  and  throws  the  heavy  weight 
of  its  displeasure  against  carelessness  or  willful  neglect.  There 
is  no  middle  ground. 


CHAPTER  III. 
ISOLATION  AND  QUAEANTINE. 

HISTORY. 

Isolation  of  the  sick,  either  by  driving  out  from  the  house,  camp 
or  town  or  by  the  other  method  of  deserting  the  sick,  has  been  in 
use  among  all  races  since  before  the  dawn  of  history.  The  word 
"Quarantine"  itself  is  derived  from  the  Italian  quarante  (forty) 
and  signifies  a  period  of  40  days'  detention  imposed  on  people  and 
vessels  coming  from  supposedly  infected  districts. 

Quarantine  may  be  declared  against  a  nation,  state,  district, 
city,  house  or  person  or  against  a  marine  vessel.  To  declare  a 
quarantine  by  no  means  makes  it  effective.  Troops  have  been  kept 
for  weeks  at  a  time  on  the  boundaries  of  countries  and  states  to 
prevent  the  introduction  of  some  dreaded  disease.  With  problems 
of  this  sort  the  local  health  officer  will  have  nothing  to  do,  except 
under  the  orders  of  his  superiors,  but  the  maintenance  of  a  dozen 
or  so  of  scattered  houses  in  proper  quarantine  will  tax  his  resources 
to  the  utmost. 

DEGREES  OF  QUARANTINE. 

There  are  several  degrees  of  quarantine.  The  most  severe  is 
the  permanenJ^  segregation  in  colonies  enforced  against  leprosy 
and  more  recently  against  African  sleeping  sickness.  The  second 
kind  is  the  "strict"  quarantine  against  the  more  dangerous  infec- 
tious diseases,  and  the  third  the  "modified"  restrictions  placed  on 
minor  or  less  communicable  conditions.  To  these  may  be  added 
segregation  of  the  inmates  of  institutions  afflicted  with  sickness 
not  dangerous  in  civil  life,  but  important  in  the  close  confinement 
of  such  places.  This  will  be  fully  treated  under  the  head  of 
' '  Institutional  Sanitation. ' ' 

There  are  also  two  measures  not  amounting  to  quarantine  which 
should  be  noticed.  These  are:  "Parole  under  Observation"  al- 
lowed certain  classes  of  contacts,  and  "Notification"  for  statistical 
purposes  and  for  the  sending  of  appropriate  literature. 

33 


34  PRACTICAL   SANITATION. 

Special  Hospitals. — The  ideal  condition  in  the  management  of 
infectious  diseases  is  the  free  use  of  special  hospitals,  to  which  the 
patient  is  removed  as  soon  as  the  diagnosis  is  made  and  where  he 
is  kept  until  all  danger  of  communicating  the  disease  is  past.  In 
crowded  tenement  districts  it  is  the  only  way  of  preventing  the 
spread  of  disease  except  by  the  employment  of  guards  day  and 
night,  and  guards  are  both  fallible  and  corruptible.  The  estab- 
lishment and  maintenance  of  emergency  hospitals  of  this  kind  will 
be  discussed  in  a  chapter  devoted  entirely  to  the  subject. 

Permanent  Segregation. — The  only  disease  in  the  United  States 
to  which  this  method  is  applied  is  leprosy.  At  least  two  states 
and  possibly  others  have  leprosaria.  The  Territory  of  Hawaii  has 
the  famous  institution  at  Molokai  and  the  Philippine  Government 
has  for  the  last  ten  years  maintained  a  similar  asylum  on  the 
Island  of  Culion.  The  local  health  officer  discovering  a  supposed 
case  of  leprosy  should  take  the  matter  up  with  his  state  Board 
of  Health,  who  will  relieve  him  of  responsibility  both  by  securing 
for  him  an  expert  diagnosis  and  arranging  for  the  care  of  his 
patient. 

Strict  Quarantine. — In  strict  quarantine  no  one  but  the  attend- 
ing physician,  the  health  officer  and  the  undertaker  (should  his 
services  become  necessary)  is  allowed  to  enter  the  house.  These 
persons  must  take  certain  precautions  on  entering  and  leaving, 
which  will  be  mentioned  later,  since  they  apply  equally  to  modified 
quarantine.  Food  and  other  supplies  must  be  deposited  at  the 
quarantine  limit,  which  should  be  indicated  by  ropes  and  flags  or 
placards,  there  to  be  taken  charge  of  by  the  inmates.  Neither 
person  nor  thing  must  be  allowed  to  pass  out  of  the  quarantine 
without  disinfection  by  the  health  officer  or  the  inspector  in  charge. 
Failure  to  observe  these  precautions  makes  the  person  committing 
the  misdemeanor  or  permitting  it  liable  to  prosecution.  Failure 
to  enforce  them  on  the  part  of  the  health  officer  makes  him  liable 
to  removal  from  office,  to  fine,  imprisonment,  or  all  three,  and 
probabl}^  makes  the  municipality  subject  to  civil  suit  if  infection 
can  be  proved  to  follow  the  neglect. 

Isolation  of  the  Sick. — Within  the  house  the  patient  and  nurse 
should  if  possible  be  entirely  isolated  from  the  rest  of  the  family. 
These  precautions  will  be  observed,  so  far  as  expedient: 

1.  "Strip"  the  room  by  removing  every  tiling  not  absolutely 
necessary  to  the  comfort  of  the  patient  and  the  health  of  the  nurse. 


ISOLATION    AND    QUARANTINE.  35 

2.  If  these  articles  are  presumably  infected,  take  them  to  an- 
other room  and  there  disinfect  them  by  the  appropriate  method. 

3.  Disinfect  the  remainder  of  the  house  if  there  is  reason  to 
believe  it  infected.^ 

4.  Set  aside  a  separate  water  closet  for  the  nurse,  if  there  is 
more  than  one.  If  she  must  share  the  one  used  by  the  family,  let 
her  use  a  chamber  pail  or  vessel  different  from  the  one  used  by 
the  patient,  disinfecting'  the  discharges  in  the  same  way  as  those 
of  the  patient  before  disposing  of  them  in  the  closet  or  vault. 

5.  Nasal,  throat,  urinary  and  fecal  discharges  must  be  received 
in  an  appropriate  vessel  partly  filled  with  a  standard  disinfectant 
solution,  and  after  being  properly  mixed  and  subjected  to  the 
action  of  the  solution  for  a  sufficiently  long  time  may  be  emptied 
into  the  vault  or  water-closet.  If  there  are  involuntary  discharges 
they  are  best  collected  in  newspapers  or  rags  which  are  burned  as 
soon  as  soiled.  Japanese  napkins  or  soft  rags  disposed  of  in  the 
same  way  are  permissible  for  nose  and  throat  secretions,  and  for 
cleansing  mouth  and  lips. 

6.  If  the  chamber  vessel  is  to  be  handled  by  others,  the  outside 
of  the  vessel  should  be  wiped  with  the  standard  solution  before 
allowing  it  to  leave  the  sick  room  and  the  hands  of  the  person 
receiving  it  must  also  be  disinfected  as  soon  as  the  vessel  is  re- 
turned to  the  nurse, 

7.  Where  the  architecture  of  the  house  permits,  the  isolation 
of  the  sick  room  may  be  made  complete  by  sealing  up  the  door 
communicating  with  the  interior  of  the  house  with  heavy  paper 
pasted  on,  and  using  only  the  outside  door  if  there  be  one,  or  a 
window  by  which  supplies  are  passed  in  and  other  articles  passed 
out  by  means  of  a  cord  and  basket,  or  better  by  a  temporary  stair- 
way or  by  a  ladder.  If  the  inner  door  communicates  with  a  hall 
having  two  stairways,  one  of  which  has  an  outside  door  opening 
directly  into  it,  the  hall  may  sometimes  be  divided  advantageously 
by  paper,  cloth  or  temporary  wooden  screens,  so  as  to  admit  of  its 
use. 

8.  If  there  is  a  stove  or  grate  in  the  room,  it  should  be  made  use 
of  to  destroy  all  soiled  cloths  and  papers  and  scraps  of  food;  or, 
they  may  be  put  into  paper  bags  and  burned  in  a  stove  or  furnace 
outside,  or  coal-oiled  and  burned  in  the  open  air. 


^  In  case  the  steps  above  recommended   are  not  practical,  leave  the  room  as  it  is   and 
use  special  care  in  disinfection  after  the  recovery  or  death  of  the  patient. 


36  PRACTICAL   SANITATION. 

9.  Dishes  must  be  disinfected  by  placing  in  a  standard  solu- 
tion for  one-half  hour  before  washing  or  removal  from  the  room; 
or,  placed  in  hot  water  and  kept  actually  boiling  for  20  minutes. 
If  possible,  dishes  and  table-ware  should  not  be  returned  to  the 
kitchen  for  washing,  but  the  same  ones  washed  and  kept  in  the 
room,  the  dishwater  being  sterilized  as  in  the  next  paragraph. 

10.  The  patient  must  be  bathed  daily,  and  the  hands  and  face 
often,  at  least  twice  daily.  The  bath  water  must  then  have  l/20th 
its  bulk  of  carbolic  acid  or  l/40th  its  bulk  of  cresol  added,  well 
stirred  into  solution  and  allowed  to  stand  for  one  hour  before  carry- 
ing out. 

11.  The  floor  must  be  swept  daily,  using  sawdust  moistened  with 
a  standard  disinfectant  solution  to  keep  down  the  dust. 

12.  If  an  interior  door  must  be  used  for  communication,  it 
should  have  a  curtain  made  of  a  heavy  sheet  hung  over  it,  which 
should  be  kept  moist  at  first  with  1 :500  bichloride  solution  and 
afterwards  mth  water.  This  door  must  be  kept  closed  except 
when  it  is  absolutely  necessary  for  some  one  to  pass. 

13.  Good  ventilation  into  the  open  air  must  be  maintained  at 
all  times  for  the  sake  of  both  patient  and  nurse. 

14.  Flies  and  mosquitoes  must  be  absolutely  excluded  by  screens 
and  any  in  the  room  must  be  destroyed. 

Isolation  of  the  sick  must  be  done  wherever  possible  as  the  period 
of  quarantine  for  contacts  begins  with  the  time  of  the  last  ex- 
posure. If,  then,  the  contacts  are  allowed  to  enter  the  sick-room, 
under  a  strictly  technical  interpretation  of  the  rule,  and  under 
some  circumstances  a  necessary  one,  the  period  of  quarantine  for 
contacts  would  begin  with  the  disinfection  of  the  house  and  the 
discharge  of  the  original  patient  from  quarantine.  It  is  also  pos- 
sible, especially  in  the  country,  to  disinfect  the  clothing  and  persons 
of  contacts  and  send  them  to  another  house  to  await  under  surveil- 
lance the  outcome  of  the  exposure.  With  the  appearance  of  the 
prodromes  of  the  disease,  they  may  then  be  transferred  to  the 
original  place  to  remain  during  their  illness,  leaving  any  remain- 
ing contacts  for  a  further  period  of  observation.  The  vehicle  and 
driver  employed  in  transferring  infectious  cases  must  be  carefully 
disinfected  before  being  employed  for  other  work. 

The  diseases  requiring  rigid  quarantine  under  the  rules  of  the 
Public  Health  Service  are : 


ISOLATION   AND    QUARANTINE.  37 

Asiatic  Cholera.  Smallpox. 

Bubonic  Plague.  Typhus  Fever. 

Yellow  Fever. 

To  these  New  York  adds :  ^ 

Diphtheria.  Scarlet  Fever. 

Measles. 

And  California  to  all  the  above: 

Anthrax  1 

™,      ,        I  occurring  m  man. 

Glanders  J 

-"  Modified  Quarantine. — In  "Modified"  quarantine,  the  wage 
earners  of  the  family  are  allowed  to  enter  and  leave  the  house  so 
long  as  isolation  as  indicated  earlier  in  this  chapter  is  properly 
carried  out,  and  provided  that  their  work  is  not  such  as  to  make 
this  course  dangerous.  This  privilege  should  not  be  accorded 
to  a  person  engaged  in  the  preparation,  care  or  sale  of  food — espe- 
cially milk,  nor  to  a  school  teacher,  and  only  so  long  as  the  fol- 
lowing precautions,  in  addition  to  the  ones  noted,  are  faithfully 
observed. 

In  an  uninfected  room  or  outhouse  he  must  have  an  uninfected 
or  disinfected  suit  of  outer  clothing.  He  must  remove  the  outer 
clothing  worn  around  the  house,  bathe  face,  hands,  arms  and 
scalp  with  soap  and  water,  and  then  with  1 :2000  bichloride  solu- 
tion or  2  per  cent  carbolic  solution  or  1  per  cent  dilution  of  com- 
pound cresol  solution  (U.  S.  P.)  or  with  an  antiseptic  soap  of 
sufficient  power.  He  puts  on  the  clean  outer  suit  and  may  then 
go  to  his  work.  A  change  of  shoes  is  not  necessary,  provided  they 
are  thoroughly  wiped  with  an  antiseptic  before  he  begins  to  change 
his  clothing.  In  case,  after  investigation,  the  necessary  care  is 
not  found  to  be  used,  the  permit  should  be  revoked  and  the  quaran- 
tine made  absolute.  Such  permit  should  always  be  written,  in 
order  that  there  may  be  no  chance  for  misunderstanding,  and 
wi'itten  or  printed  slips  conveying  the  above  directions  are  also 
useful. 

The  list  of  diseases  for  which  modified  quarantine  is  allowable 
under  the  rules  of  most  health  boards  follows : 


1  New  York  City  places  these  under  Modified  Quarantine. 


38  PRACTICAL  SANITATION. 

Diphtheria.  Kubella. 

Measles.  Scarlet  Fever, 

Epidemic  cerebrospinal  meningitis.  Whooping  congh. 

Anterior  poliomyelitis  (infantile  paralysis). 

Placarded  Diseases. — ^In  the  practice  of  some  boards  the  follow- 
ing diseases  are  allowed  to  be  placarded  without  quarantine: 

Measles.  Typhoid  Fever. 

Whooping  cough.  Chicken-pox. 

Exclusion  from  School. — -Any  of  the  diseases  above  named 
should  exclude  the  other  members  of  the  family  from  school,  either 
as  teacher  or  pupils.  No  teacher  or  child  having  any  of  the  fol- 
lowing conditions  should  be  permitted  to  be  in  school: 

Hard  cough. 

Severe  cold. 

Influenza. 

Itch. 

Ringworm. 

Tinea  tonsurans  (scald  head). 

Impetigo  contagiosa. 

Granulated  eye  lids.- 

Purulent,  granular  or  trachomatous  conjunctivitis. 

Lice  or  other  parasites. 

Placards  and  Flags. — The  requirements  under  the  various  stat- 
utes and  rules  differ  so  greatly  that  no  directions  can  be  given 
beyond  saying  that  the  law  of  his  own  state  muft  be  followed  im- 
plicitly with  regard  to  them,  otherwise  the  health  officer  may  find 
himself  without  a  leg  to  stand  on  when  he  desires  to  prosecute 
violations  of  the  law. 

Personal  Precautions. — ^There  are  certain  precautions  which  the 
health  officer,  the  physician  and  the  undertaker  must  observe  in 
dealing  with  diseases  listed  in  the  first  and  second  classes  of  quar- 
antine. Everyone  whose  duties  call  him  into  relation  with  these 
infections  should  be  provided  with  sterilizable  overall  clothing  of 
some  kind.  Some  prefer  a  long  hooded  gown,  covering  completely 
all  the  body  but  the  face.  Others  use  a  simple  duck  or  denim 
suit  of  jumper  and  trousers,  and  a  large  white  cap.  If  a  beard  is 
worn,  it  should  be  covered  with  gauze  or  a  towel.     In  the  presence 


ISOLATION    AND    QUARANTINE.  39 

of  pneumonic  cases  of  plague,  a  mask  should  be  worn,  wet  with 
an  antiseptic. 

Whichever  costume  is  adopted  is  thoroughly  soaked  with  bi- 
chloride solution  1 :1000,  and  dried.  It  may  then  be  sterilized  by 
simply  dampening  thoroughly  and  rolling  into  a  bundle,  which  is 
placed  in  a  satchel  or  rubber  cover,  and  will  be  ready  for  use  again 
in  a  few  minutes.  Bichloride  or  other  standard  antiseptic  solu- 
tion should  be  used  on  the  shoes  or  rubbers  before  leaving  the  place. 

Person. — The  hair  and  beard  must  be  thoroughly  moistened 
with  1:2000  bichloride  or  other  antiseptic  of  equal  power.  The 
hands  must  be  washed  with  soap  and  water  and  then  with  an  anti- 
septic. 

Instruments. — Thermometers  and  other  instruments  used  in  the 
sick  room  must  be  washed  with  carbolic  acid  1 :20,  formalin  1 :20, 
or  cresol  2  per  cent.  It  is  best  to  have  one  thermometer  for  each 
house.  Tongue  depressors  and  applicators  of  wood  are  cheap,  and 
are  burned  at  once. 

Clothing. — On  reaching  home  all  clothing  should  be  changed 
and  placed  in  a  closet,  box  or  wardrobe  where  it  can  be  sterilized 
with  formaldehyd  gas,  using  the  amounts  of  formalin  and  per- 
manganate appropriate  to  the  cubic  contents  of  the  receptacle. 
With  a  careful  bath,  at  least  of  the  exposed  parts  of  the  person, 
and  fresh  clothing,  the  disinfection  is  complete. 
■  Contacts  and  Convalescents. — These  methods  must  also  be 
used  "with  contacts,  convalescents,  and  inununes  released  from  quar- 
antine. In  the  case  of  those  recovered  from  scarlet  fever  and 
smallpox  the  antiseptic  bath  should  be  given  twice  on  successive 
days  before  release,  using  soap  and  water  with  plenty  of  friction 
before  the  antiseptic,  and  paying  particular  attention  to  the  scalp 
and  hairy  parts  of  the  body. 

Pets. — Dogs,  cats,  birds  or  other  pets  must  not  on  any  account 
be  allowed  to  remain  in  a  quarantined  house.  Their  hair,  fur  or 
feathers  make  them  excellent  carriers  of  infection  from  house  to 
house,  and  in  the  case  of  cats  and  dogs,  mingling  with  others  of 
their  kind,  makes  possible  infection  which  may  over-spread  a  city 
when  every  human  being  has  complied  with  the  law.  Before  being 
excluded  from  the  house  such  animals  must  be  disinfected  with 
carbolic  acid  5  per  cent  or  cresol  solution  2  per  cent,  sufficient  to 
saturate  the  skin  thoroughly. 

Vermin. — Since  rats  and  mice  are  more  than  suspected  of  being 


40  PRACTICAL   SANITATION. 

active  agents  in  the  spread  of  disease,  a  determined  effort  should 
be  made  to  rid  the  premises  of  them  by  poison  and  traps. 

So  far  as  possible  the  house  must  be  rid  not  only  of  flies  and 
mosquitoes,  but  roaches  and  bedbugs.  While  only  the  first  two 
are  known  to  be  disease  carriers,  other  insects  may  also  play  a 
part,  and  it  is  wise  to  close  every  avenue  which  may  permit  the 
spread  of  infection. 


CHAPTER  IV. 
ISOLATION  HOSPITALS  AND  CAMPS. 

Isolation  hospitals  and  camps  are  worthy  of  more  extensive  use 
than  is  nsually  made  of  them  in  American  practice  outside  of  the 
larger  cities.  They  are  of  the  greatest  service  in  the  management 
of  smallpox,  Asiatic  cholera,  yellow  fever,  typhus  and  plague,  and 
there  are  certain  other  diseases  such  as  the  mediaeval  sweating 
sickness,  still  surviving  in  isolated  places  in  Europe,  which  would 
make  them  an  imperative  need.  It  is  also  usual,  in  Great  Britain 
and  some  other  European  countries,  to  treat  diphtheria,  scarlet 
fever  and  measles  in  special  hospitals.  This  is  beyond  all  question 
the  best  practice,  but  except  in  very  severe  epidemics  would  not  be 
approved  by  the  public  in  this  country,  at  least  in  the  smaller 
places. 

Site. — Having  decided  on  the  necessity  for  an  emergency  hos- 
pital, the  first  thing  is  to  secure  an  eligible  site,  either  by  purchase, 
seizure  or  lease.  This  should  be  done  under  competent  legal  ad- 
vice, in  strict  accordance  with  the  statutes.  Otherwise,  wearisome 
and  costly  litigation  may  follow. 

From  the  sanitary  standpoint  the  following  considerations  must 
govern : 

1.  Convenience  of  access  to  good  roads. 

2.  A  distance  from  city  limits  of  1  to  2  miles. 

3.  A  distance  of  600  feet  from  inhabited  houses. 

4.  A  good  and  plentiful  water  supply. 

5.  Good  natural  or  artificial  drainage. 

6.  Sufficient  area  for  all  hospital  purposes. 

7.  Shade  and  grass,  so  that  out-of-doors  may  be  pleasant. 

8.  Buildings  adapted  or  adaptable  to  hospital  use. 

9.  Electric  current  and  telephone  available. 

Constniction. — Having  made  a  selection  of  a  site,  the  buildings 
are  to  be  inspected  with  a  view  to  their  best  utilization.  These 
may  be  old  residences,  warehouses  or  barns,  or  possibly  some  sub- 

41 


42  PRACTICAL   SANITATION. 

urban  hotel  or  Chautauqua  buildings  left  stranded  by  the  collapse 
of  a  boom.  These  must  be  judged  on  their  merits  according  to  the 
following  standards: 

1.  Ventilation ;  is  it  good  ? 

2.  Can  the  place — especially  the  wards — be  well  heated? 

3.  Can  1,200  cubic  feet  of  air  space  and  120  square  feet  of  floor 
space  be  allotted  to  each  patient  ? 

4.  If  conditions  become  unexpectedly  worse  can  the  arrange- 
ments be  readily  expanded  to  care  for  the  increased  needs? 

5.  Is  there  room  for  at  least  two  wards,  kitchens,  store  rooms, 
dining  room,  lavatory,  laundry,  nurses'  quarters,  physician's  quar- 
ters, dispensary,  morgue,  sterilizing  room,  guard  room  ? 

6.  Is  sewerage  available?  If  vaults  must  be  used  is  there  a 
good  location?  Is  there  room  to  improvise  or  install  a  garbage 
crematory  ? 

7.  Is  there  stable  and  shed  room  for  ambulance  and  horses? 

8.  Is  there  room  for  a  camp  for  contacts?  Isolation  quarters 
for  convalescents? 

9.  If  not  already  in,  can  electric  current  be  installed?  Tele- 
phone ? 

These  things  are  not  equally  necessary,  and  every  case  must  be 
decided  on  its  merits.  Sometimes  the  same  room  or  building  may 
be  used  for  two  diverse  things.  For  instance,  the  laundry  may  be 
used  as  the  sterilizing  room  or  the  doctor  may  sleep  in  the  dis- 
pensary, but  if  the  epidemic  is  at  all  an  extensive  one,  all  these 
things  will  be  required  and  probably  space  will  be  needed  for  pur- 
poses which  cannot  be  foreseen.  Certainly  a  few  private  rooms 
in  which  the  dying  may  lie  are  an  advantage. 

To  take  up  the  foregoing  considerations  in  detail : 

Ventilation. — No  infectious  disease  hospital  should  have  a  less 
floor  space  per  patient  than  120  square  feet  and  a  content  per  pa- 
tient of  1,200,  or  better,  1,500  cubic  feet.  To  secure  ventilation  in 
the  first  case,  the  atmosphere  must  be  changed  four  times  per  hour 
and  in  the  latter  three  times. 

If  gas  or  oil  lamps  are  used,  somewhat  more  space  will  be  needed, 
as  they  help  to  vitiate  the  air  and  by  their  flickering  make  its  rapid 
change  unpleasant.  A  more  rapid  change  than  four  times  in  the 
hour  also  creates  a  feeling  of  draft.  To  ascertain  the  rate  of 
change,  the  room  is  filled  with  the  smoke  from  burning  rags  or 


ISOLATION   HOSPITALS  AND   CAMPS.  43 

paper  with  ventilators  closed.  The  ventilators  are  then  opened 
and  the  time  for  the  air  to  become  clear  is  noted.  Since  it  is 
hardly  probable  that  any  modern  system  of  ventilation  is  in  place, 
a  substitute  must  be  improvised.  If  there  is  a  sufficiency  of  win- 
dows, the  problem  is  easy. 

Screens. — The  windows  and  all  other  openings  in  the  house  are 
first  provided  with  small  mesh  screens,  if  the  weather  is  at  all  warm 
or  if  the  epidemic  is  likely  to  continue  into  warm  weather.  Thin 
pieces  of  board  6  inches  high  are  fastened  to  the  inside  of  the 
window  casings  from  side  to  side,  so  forcing  any  draft  which  may 
come  through  the  opened  window  toward  the  ceiling.  Movable 
screens  between  window  and  patient  may  also  be  used  as  shelter 
from  undesirable  air  currents.  If  electric  current  is  to  be  had, 
small  fans  assist  wonderfully.  If  there  is  a  grate  or  fireplace  in 
the  room,  a  small  fire  should  be  kept  constantly  burning  in  it  for 
its  ventilating  efi:ect.  If  there  is  any  bad  odor  in  the  room,  the 
air  is  not  changed  sufficiently  often  and  the  defect  must  be  cor- 
rected. 

Heating. — There  should  be  provision  for  heating  at  least  part  of 
the  hospital  even  in  warm  weather,  as  there  may  be  collapsed  pa- 
tients in  the  cool  hours  of  the  early  morning  who  will  need  a  high 
room  temperature.  Some  means  must  be  provided  for  holding  the 
room  temperature  all  the  time  at  a  point  between  68°  and  72°. 
The  means  will  vary  and  every  case  must  be  settled  as  it  best  can. 

Moisture. — It  must  not  be  forgotten  that  a  very  great  factor  in 
securing  an  equable  temperature  is  an  atmosphere  properly  mois- 
tened. A  hygrometer  for  determining  the  water  content  of  the 
air  is  almost  as  important  as  a  thermometer.  It  should  never  be 
allowed  to  show  less  than  60  per  cent  of  saturation  at  70°.  If  too 
low,  the  water  vapor  may  be  added  by  boiling  water  on  a  stove 
or  oil  or  spirit  lamp,  or  by  exposing  dampened  sheets  in  the  room.^ 

Wards. — These  should  be  not  less  than  two  in  number  for  adults, 
and  one  or  two  more  for  children  will  be  an  advantage  if  there 
is  a  large  number  of  patients  to  be  cared  for.  There  should  also 
be  private  rooms  for  the  very  sick  and  for  those  having  other  infec- 
tious diseases  as  complications. 

There  must  be  the  amount  of  floor  space  and  cubic  contents  al- 
ready mentioned  as  necessary  for  each  bed,  and  this  'space  must 
be  so  distributed  that  there  is  passageway  around  each  bed,  with 


^  This  does  not  apply  to  summer  conditions,   except  in  very  dry  weather. 


44  PRACTICAL   SANITATION. 

screens  in  place.  The  ward  furniture  will  be  discussed  later  in  this 
chapter  under  the  head  of  Supplies. 

Kitchens. — Two  kitchens  are  necessary  in  an  infectious  disease 
hospital — a  diet  kitchen  for  the  sick  and  an  entirely  separate  place 
where  the  food  for  the  employees  is  prepared.  To  allow  nurses 
and  the  sick  to  eat  from  the  same  utensils  is  to  court  infection,  be- 
cause some  slip  in  the  technique  of  disinfection  may  take  place. 
If  possible  a  trained  nurse  should  be  in  charge  of  the  diet,  as  in 
the  infectious  diseases  proper  diet  is  highly  essential. 

The  diet  kitchen  should  be  furnished  with  a  coal-oil  or  gasoline 
stove,  or  better,  a  hot  plate,  either  electric  or  gas.  A  fireless 
cooker  will  greatly  lighten  the  work,  and  will  without  trouble  pro- 
vide hot  broths  and  soups  at  all  hours.  Vacuum  bottles  may  also 
be  used  to  keep  food  and  drinks  hot  at  the  bedside. 

The  employees'  kitchen  should  preferably  be  as  far  from  the 
wards  as  possible  or  in  another  building,  or  if  the  weather  is  warm, 
a  screened  tent  may  be  used,  with  another  screened  tent  or  shack 
as  a  dining  room.  Since  the  duties  of  attendants  are  sure  to  make 
the  meal  hours  very  irregular,  a  fireless  cooker  will  be  a  good  in- 
vestment for  this  kitchen  also.  It  is  a  great  advantage  in  that  it 
will  provide  hot  meals  for  the  night  attendants  without  requiring 
a  night  cook. 

Store  Rooms. — Of  these  there  should  be  two — one  near  the  wards 
for  a  linen  and  spare  furniture  room  and  the  other  near  the  kitchen 
for  food  and  cooking  utensils. 

Dining  Room. — This  should  be  carefully  screened,  as  far  as  pos- 
sible from  the  wards,  and  for  the  use  of  officers  and  employees 
only. 

Lavatory. — This  is  a  most  important  room,  since  it  is  there  that 
the  personal  disinfection  of  the  staff  will  be  done.  It  should  be 
well  supplied  with  water,  and  best  by  running  water;  if  it  has 
not  running  hot  water,  there  should  be  means  for  keeping  water 
hot  all  the  time.  There  must  be  an  ample  supply  of  disinfectants 
of  standard  type,  and  no  wash  slops  should  either  be  thrown  out 
or  run  into  the  sewer  till  they  have  been  thoroughly  disinfected. 

Laundry. — The  laundry  is  arranged  like  any  other  laundry,  but 
nothing  is  allowed  to  go  to  it  for  cleansing  until  it  has  been  im- 
mersed either  in  boiling  water  or  a  disinfectant  solution  for  a 
sufficient  length  of  time. 

Nurses'  Quarters. — -These  should  be  well  ventilated  and  com- 


ISOLATION    HOSPITALS   AND    CAMPS.  45 

fortable  and  are  best  provided  in  a  separate  building.  At  least 
one  room  must  be  capable  of  being  darkened  so  that  the  night 
nurse  or  nurses  may  sleep  well  when  off  duty. 

Physician's  Quarters. — The  doctor's  quarters  call  for  no  spe- 
cial comment.  Since  he  is  in  charge  of  the  hospital,  it  is  his  own 
fault  if  he  is  not  comfortable. 

Dispensary  and  Office, — This  room  should  be  well  lighted  and 
provided  with  a  table  or  two,  a  desk,  some  chairs  and  a  set  of 
shelves.  The  list  of  drugs  required  is  not  extensive  and  will 
readily  suggest  itself  to  any  experienced  physician. 

Morgue. — Provision  must  be  made  for  a  morgue,  since  there 
will  inevitably  be  deaths,  and  the  dead  must  be  handled  with  as 
little  shock  to  the  susceptibilities  of  the  living  as  possible,  while 
preserving  the  public  interests  unimpaired.  Modern  embalming 
fluids  are  excellent  disinfectants,  and  if  bodies  are  embalmed  with 
them,  wrapped  in  absorbent  cotton  or  blankets  soaked  in  1 :500 
bichloride  solution,  and  placed  in  cheap  metallic  coffins,  hermet- 
ically sealed,  the  public  health  will  be  duly  guarded  and  no  one 
offended.  Cremation  is  the  best  way  of  disposing  of  such  cadavers, 
but  crematories  are  rarely  accessible  from  an  improvised  hospital 
of  this  kind,  and  public  sentiment  would  certainly  resent  the  use 
of  the  open  funeral  pyre  except  under  stress  of  the  direst  necessity. 

Guard  Koom. — A  guard  to  prevent  contacts,  convalescents,  and 
derelict  employees  from  breaking  quarantine  is  advisable,  and 
often  imperative.  Either  regular  or  special  police,  or  deputy 
sheriffs  may  be  employed,  and  National  Guard  troops  have  on 
rare  occasions  been  used  in  this  way.  The  guard  must  have  suit- 
able quarters  outside  the  quarantine  limits,  and  be  subsisted  wholly 
outside  the  hospital. 

Sterilizing  Room. — A  sterilizing  room  where  infected  articles 
may  be  disinfected  by  any  appropriate  means  is  a  convenience. 
Its  use  may  be  obviated  by  putting  infected  articles  in  the  wards 
into  covered  pails  which  are  then  partly  or  completely  filled  with 
a  disinfectant,  the  outside  of  the  pail  being  mopped  with  the  disin- 
fectant, when  the  pail  may  be  taken  to  the  laundry,  and  after 
sufficient  exposure,  the  articles  may  be  washed. 

Sewerage. — ^Sewer  or  cesspool  connection  makes  a  site  much 
more  desirable  for  hospital  purposes.  If  not  available,  closets  of 
the  type  described  in  Chapter  XXXII  are  excellent  substitutes. 

Sinks  and  Vaults. — If  these  are  used,  they  must  be  dug  to  a 


46  PRACTICAL,   SANITATION. 

depth  of  at  least  8  feet,  must  be  screened  so  as  to  be  absolutely 
flyproof,  and  crude  carbolic  acid  or  cresol  in  milky  emulsion  of  5 
to  10  per  cent  applied  freely  every  few  hours.  Freshly  made 
milk  of  lime  may  also  be  used  but  is  hardly  so  effective. 

Incinerators  and  Crematories. — These  are  of  two  kinds,  one 
replacing  the  water  closet  or  privy  vault  and  the  other  the  garbage 
cremator}'-.  They  are  portable,  easily  installed,  not  very  expensive 
in  first  cost,  economical  in  operation,  inoffensive,  and  absolutely 
comply  with  sanitary  requirements.  There  are  several  types  of 
them  made  by  different  firms,  all  of  which  are  capable  of  doing 
satisfactory  work. 

An  improvised  garbage  crematory  which  will  do  good  work  is 
made  by  digging  a  trench  2^  feet  wide  and  5  or  6  feet  long,  6 
inches  deep  at  the  upper  end  and  12  inches  at  the  lower  end.  This 
is  then  filled  with  boulders  and  a  fire  built  until  the  stones  are 
thoroughly  heated.  Slops  are  poured  in  at  the  upper  end  and 
by  their  passage  through  the  hot  stones  are  evaporated;  the  solid 
parts  after  drying  are  raked  into  the  fire  to  be  burned.  If  long 
used,  it  has  to  be  cleaned  out  and  the  ashes  removed. 

Semi-dry  garbage  may  be  well  mixed  with  crude  petroleum  and 
straw,  and  burned  either  in  the  open  or  in  a  pit.  The  odors  aris- 
ing from  this  method  are  unpleasant  but  not  unsanitary. 

Stables. — 'Stable  room  must  be  provided  for  the  ambulance 
horses  and  ambulance. 

Contacts  and  Convalescents. — If  the  weather  is  at  all  suitable, 
these  are  best  cared  for  in  tents  or  in  shacks  of  light  construction, 
(yontacts  should  do  their  own  cooking  and  cleaning,  but  conva- 
lescents will  require  a  nurse  and  cook.  If  the  wards  are  not  too 
crowded,  convalescents  may  remain  there  until  just  before  dis- 
charge. 

Supplies. — The  supplies  for  an  emergency  infectious  disease 
hospital  of  this  kind  are  necessarily  bought  without  bids  wherever 
the  needed  articles  can  be  procured  in  time,  and  fortunately  are 
of  a  type  to  be  obtained  almost  anywhere.  They  fall  naturally 
into  the  following  classes: 

1.  Ward  supplies. 

2.  Kitchen  and  dining  room  supplies. 

3.  Medical  supplies. 

4.  Transportation. 

5.  Food. 


ISOLATION    HOSPITALS   AND    CAMPS.  47 

Ward  Supplies. — These  are  of  the  simplest  nature  compatible 
with  the  comfort  and  well-being  of  the  patients.  Canvas  cots  are 
comfortable,  cheap,  easily  cleaned  and  easily  handled.  They  should 
have  a  doubled  cotton  comfort  over  them  as  a  cushion  and  to  pre- 
vent too  sudden  changes  of  temperature.  The  comfort  may  be 
reinforced  by  a  few  old  newspapers  next  the  canvas  for  warmth, 
or  a  bedsack  filled  with  straw  may  be  used.  Spring  cots  with 
cotton  mattresses  are  sometimes  more  easily  procurable  and  will 
do  nicely. 

Pillows  should  be  of  cotton,  woven  wire  or  rubber  cushions,  but 
in  the  case  of  the  first  two,  should  have  a  cover  of  rubber  sheeting 
under  the  slip. 

The  cotton  comforts  mentioned  above  and  cotton  blankets  are 
to  be  had  very  cheaply  in  quantities,  if  there  is  time  for  negotiation. 

Cheap  unbleached  or  half-bleached  cotton  sheets  should  be  pro- 
cured in  good  quantity;  or  better,  paper  sheets  and  pillow  cases 
which  can  be  destroyed  as  soon  as  soiled.  Paper  towels  and  napkins 
are  also  cheap  and  convenient. 

Old  linen  may  be  received  from  the  outside  to  be  used  and  then 
destroyed,  but  unless  its  source  is  definitely  known,  it  is  better  to 
fumigate  it  with  formaldehyd  before  using.  It  would  not  in  the 
least  simplify  matters  to  have  smallpox  or  scarlet  fever  introduced 
into  a  plague  hospital  in  old  clothing. 

The  cheapest  nightgowns  in  assorted  sizes  should  also  be  bought 
in  as  large  quantities  as  may  be  thought  necessary  with  a  per- 
centage over,  to  be  sure  of  having  enough. 

Naturally,  not  all  these  things  need  be  brought  to  the  hospital 
on  the  opening  day,  but  a  sufiicient  reserve  must  be  held  in  easy 
reach  for  unforeseen  necessities. 

Boxes  will  serve  as  bedside  tables  unless  a  sufficient  supply  of 
inexpensive  small  tables  is  in  reach.  Folding  sewing  tables  are 
sheap  and  do  not  take  up  much  room. 

Plain  kitchen  chairs  and  a  few  rockers  and  canvas  steamer  chairs 
complete  this  part  of  the  ward  equipment. 

Each  bed  should  also  have  the  following  articles: 

Enameled  basin.  Rubber  or  waterproof  blanket. 

Enameled  sputum  cup.  Hot  water  can  or  bottle. 

China  feeding  cup.  Diet  tray. 

Bent  glass  tube  for  drinking.  2  towels,  small. 

Pus  basin  or  shallow  pan.  1  towel,  large. 

Chamber  vessel. 


48  PRACTICAL   SANITATION, 

To  each  2  beds: 

1  slop  pail. 

1  water  pail    ( covered ) . 

1  bed  pan. 

To  each  4  beds : 

1  urinal. 

The  ward  as  a  whole  must  be  abundantly  supplied  with  irri- 
gators for  saline  enemata,  and  subcutaneous  or  intravenous  injec- 
tions, hypodermic  syringes,  catheters,  dressing  forceps,  gauze, 
cotton  and  old  cloths.  There  should  also  be  some  means  of  heating 
water  quickly. 

Dining  Room  and  Kitchen. — The  furniture  for  these  rooms  is 
of  the  simplest  variety,  boards  laid  on  tressels  or  the  cheapest  of 
kitchen  tables  and  ordinary  wooden  or  camp  stools  or  chairs  being 
sufficient.  Enamel  ware  is  best  for  table  use,  as  it  can  be  boiled 
or  treated  with  antiseptics  without  injury. 

Food. — For  the  sick,  milk  (fresh,  malted  and  condensed),  with 
fruits,  fruit  juices,  cereals,  tea,  coffee,  cocoa,  and  bread  and  meats 
fresh  daily,  will  give  a  sufficient  dietary.  If  a  skilled  diet  cook 
cannot  be  had,  a  few  minutes'  study  of  the  catalogues  of  the  large 
packing  or  preserving  houses  will  show  a  large  number  of  desirable 
articles  in  the  way  of  soups  and  broths.  The  large  biscuit  factories 
also  make  many  articles  of  invalid's  diet,  and  almost  any  of  the 
breakfast  foods  is  desirable.  Beef  extract  for  its  stimulant  value 
should  not  be  forgotten,  and  some  of  the  predigested  foods  should 
be  at  hand  for  the  very  weak. 

For  the  attendants,  the  food  must  be  of  the  best  quality,  and 
prepared  and  served  in  the  best  manner.  They  are  entitled  to  be 
well-nourished  in  order  to  resist  infection. 

Medical  Supplies. — Any  standard  work  on  practice  will  sug- 
gest the  articles  likely  to  be  needed,  but  the  supply  need  not  be 
elaborate. 

Telephone. — A  telephone  is  a  necessity,  but  will  be  an  unmiti- 
gated nuisance  unless  ringing-in  is  allowed  only  to  those  who  give 
a  secret  number  or  pass,  which  can  be  changed  daily  if  desired. 

Electric  Wiring. — ^If  at  all  possible,  electric  wiring  should  be 
installed,  as  the  power  may  be  used  not  only  for  lighting,  but  for 
ventilating  fans,  for  hot  plates,  for  bed  warmers,  and  to  furnish 


ISOLATION    HOSPITALS   AND    CAMPS.  49 

power  for  a  vacuum  cleaner,  which  by  collecting  the  dirt  in  a  place 
where  it  can  readily  be  destroyed,  minimizes  chances  for  infec- 
tion. 

Transportation. — The  proper  transportation  for  persons  sick  of 
infectious  diseases  is  a  closed  vehicle  in  which  one  or  two  persons 
may  ride  lying  down.  The  ambulance  of  the  U.  S.  Army  type  is 
the  best  form  of  conveyance,  but  a  fairly  good  one  may  be  made 
by  taking  a  small  spring  wagon  with  a  top,  side  and  end  curtains, 
and  fitting  it  with  two  narrow  litters. 

If  the  demands  are  not  heavy,  a  canvas  cot  may  be  used  in  place 
of  the  litters,  but  cots  are  too  wide  as  a  rule  for  more  than  one 
to  be  carried  at  a  time. 

The  ambulance  should  be  marked  with  a  yellow  quarantine  flag 
and  a  green  St.  Andrew's  cross.  The  Red  Cross  is  forbidden  by 
law  and  treaty  to  all  but  neutralized  members  of  belligerent  par- 
ties in  war  time,  and  to  the  Red  Cross  Society  itself. 

The  personnel  of  the  ambulance  consists  of  the  driver  and  a 
medical  inspector  who  makes  sure  of  the  diagnosis  before  removing 
the  patient  to  the  hospital.  They  may  wear  a  brassard  on  the  arm 
or  the  green  St.  Andrew's  cross  on  a  white  ground  as  a  badge  of 
authority,  if  desired,  in  place  of  the  hitherto  customary  Red  Cross. 

The  material  carried  should  include  beside  the  litters,  an  emer- 
gency case  with  hypodermic  solutions  already  prepared,  a  bottle 
of  aromatic  ammonia,  bichloride  tablets,  a  pus  basin  and  cloths 
for  vomited  matters,  a  water  proof  sheet,  and  restraint  apparatus 
for  delirious  patients. 

All  of  these  materials,  including  the  inside  and  outside  of  the 
ambulance,  should  be  appropriately  disinfected  from  time  to  time. 

In  case  of  resistance,  the  police  or  other  peace  officers  should  be 
called  on  to  assist  in  the  removal. 

Accounts. — The  accounts  of  a  hospital  are  not  necessarily  com- 
plicated, but  must  be  complete.     They  comprise: 

1.  Property  purchased. 

2.  Property  expended. 

3.  Inventory.     (This  checks  the  balance  between  1  and  2.) 

4.  Time  book  and  payroll  of  employees. 

5.  Inventory  book  of  patients'  property. 

6.  Descriptive  book  of  patients. 

7.  Numerical  account  of  patients.  -^ 

8.  Morgue  list  of  places  of  interment. 


50  PRACTICAL  SANITATION. 

The  titles  of  these  are  self  explanatory  except  Nos.  6  and  7.  The 
descriptive  book  should  be  ruled  horizontally  so  that  one  line  is 
given  to  each  patient,  and  vertically  to  allow  the  insertion  of  the 
following  headings : 

1.  Name. 

2.  Sex. 

3.  Kace. 

4.  Nationality. 

5.  Age. 

6.  Social  condition  (single,  married,  widowed,  divorced). 

7.  When  taken  sick? 

8.  Where  taken  sick? 

9.  Admitted  (month,  day,  hour). 

10.  Diagnosis. 

11.  Complications. 

12.  Final  disposition  (died,  discharged,  date).^ 

The  numerical  account  of  patients  gives  the  number  of  patients 
received  each  day,  and  in  the  wards  from  the  day  before,  and  the 
number  of  patients  discharged  or  who  have  died.  The  balance 
equals  the  number  present  for  treatment  on  the  following  day.  A 
similar  account  should  be  kept  for  the  isolation  camp  for  contacts. 
Patients  are  mentioned  by  name  only  on  admission  or  at  final  dis- 
position. During  treatment  they  are  carried  as  units  in  the  total 
number.  Thus  account  No.  7  must  always  balance  with  the  totals 
admitted,  treated,  and  finally  disposed  of  as  shown  by  account  No.  6. 

Recapitulation. — To  be  sure  that  all  the  steps  involved  in  the 
admission  and  final  disposition  of  a  patient  are  correctly  under- 
stood, let  us  consider  the  case  of  Mrs.  A.,  sick  in  a  railroad  camp 
in  the  sanitary  district  of  Beeville,  which  place  has  established  a 
hospital  to  care  for  all  cases  of  smallpox. 

1.  The  rumor  reaches  the  Health  Officer. 

2.  He  investigates;  finds  it  true. 

3.  Notifies  hospital. 

4.  Ambulance  comes;  medical  inspector  concurs  in  diagnosis 
(the  concurrence  of  two  physicians  is  usually  required  for  removal 
to  contagious  disease  hospital). 

5.  Prepares  to  remove  patient ;  husband  and  friends  resist. 


1  This  may  also  be  used  as  a  card  form. 


ISOLATION    HOSPITALS   AND    CAMPS.  51 

6.  Police  summoned;  patient  forcibly  removed. 

7.  Quarantine  squad  called;  shack  disinfected;  inmates  vacci- 
nated; either  quarantined  in  house  or  removed  under  guard  to 
contact  camp, 

8.  Mrs.  A.  arrives  at  hospital ;  inventory  made  of  accompanying 
property  or  money;  property  then  sealed  in  paper  bag  and  disin- 
fected; clothing  of  no  value  destroyed. 

9.  If  condition  permits,  is  given  bath  and  haircut  in  bathroom ; 
if  not,  is  attended  to  in  bed. 

10.  "Ward  sheet  made  up  (history,  orders,  etc.). 

11.  Descriptive  list  made  up  from  data  furnished  by  medical 
inspector,  or  patient. 

12.  After  25  days  has  completely  desquamated;  is  given  disin- 
fecting baths  on  two  successive  days  and  discharged,  or 

12a.  Dies  on  fourth  day;  body  taken  to  morgue;  prepared  ac- 
cording to  rule ;  buried  within  24  hours ;  record  of  place  and  time 
of  burial  entered  in  morgue  book;  if  any  property  of  value  or 
money  accompanied  her  to  the  hospital,  it  is  returned  to  her  family 
or  turned  over  to  the  proper  public  official,  taking  receipts  in 
writing. 

Laws. — The  laws  under  which  authority  is  given  for  the  estab- 
lishment of  hospitals  for  dangerous  epidemic  diseases  are  diverse 
and  subject  to  not  infrequent  changes  by  new  legislation.  As  ad- 
vised in  the  earlier  paragraphs  of  this  chapter,  the  health  officer 
will  do  best  to  take  every  step  under  competent  legal  advice,  which 
can  inform  him  exactly  what  to  do  under  his  peculiar  local  con- 
ditions. 

As  a  necessary  part  of  the  quarantine  power  of  the  state  ''to 
place  in  confinement  and  to  submit  to  regular  medical  treatment 
those  who  are  suffering  from  some  contagious  or  infectious  disease 
on  account  of  the  danger  to  which  the  public  would  be  exposed  if 
they  were  permitted  to  go  at  large"  it  "is  so  free  from  doubt 
that  it  has  rarely  been  questioned."  (State  vs.  Berg,  70  N.  W. 
Bep.) 

In  general  these  laws  allow  the  employment  of  all  necessary  help, 
and  state  to  what  municipality  the  expense  is  chargeable.  No 
part  of  the  expense  is  collectible  from  the  patients  or  their  families, 
since  they  are  involuntarily  removed  there  for  the  protection 
of  the  public,   and  not  for  their  own   convenience,   pleasure   or 


52  PRACTICAL   SANITATION. 

profit.     Since  this  is  done  for  the  public  benefit,  the  public  must 
pay  for  it. 

Since,  too,  the  finding  of  the  health  officer  is  not  subject  to  re- 
view by  any  court,  it  behooves  him  to  be  in  every  way  sure  of  his 
diagnosis  before  removing  a  suspect  to  a  place  where,  if  not  in- 
fected, he  might  contract  a  fatal  illness.  Absolute  certainty  is 
required  before  using  the  most  arbitrary  power  confided  to  any 
civil  officer  or  indeed  to  any  officer  in  time  of  peace. 


CHAPTER  V. 
DISINFECTION. 

GENERAL  CONSIDERATIONS. 

Disinfection  is  thp  (destruction  of  disease  fff^r^s  Hy  any  Tnp.tho^l, 
The  ^-reat  natural  disinfectants  »re>  sr|]pr  1io;ht.  rlpsiVp.atinn^aiid.frp.sli 
air  with  its  ozone.  If  every  part  of  the  thing  to  be  disinfected  could 
be  exposed  to  their  action  for  a  sufficiently  long  time,  nothing  else 
would  be  required;  but  since  sunlight  is  not  always  available,  and 
cannot  always  be  brought  to  the  spot  desired,  and  since  fresh  air 
cannot  always  be  made  to  penetrate  to  the  recesses  of  the  article 
to  be  disinfected,  we  are  forced  to  supplement  them  by  artificial 
disinfectants^which  are  in  the  order  of  their  efficiency : 

1.  Fire. 

2.  Superheated  Steam. 

3.  Boiling. 

4.  Streaming  Steam. 

5.  Dry  Heat. 

6.  Chemical  Disinfection. 

Each  of  these  agencies,  properly  handled,  is  effective;  but  used 
carelessly,  none  of  them  is  of  any  value.  Improperly  done,  they 
are  positively  harmful  by  giving  a  false  sense  of  security.  The 
method  of  using  each,  with  the  indications  special  to  its  employ- 
ment, follows: 

Fire. — This  method  is  absolutely  sure,  and  is  the  only  means  to 
be  thought  of  for  the  disinfection  of  soiled  rags  and  papers,  tubercu- 
lar sputum,  soiled  dressings  from  pus  cases,  and  bedding  of  little 
value  infected  with  any  of  the  more  resistant  pathogenic  microbes. 
To  be  of  value,  the  infected  articles  must  be  burned  at  once,  and 
not  allowed  to  accumulate. 

Superheated  Steam. — This  mode  requires  expensive  apparatus 
which  places  it  out  of  the  reach  of  any  but  wealthy  municipalities. 
The  material  to  be  disinfected  is  placed  in  large  iron  cylinders, 
from  which  the  air  is  exhausted,  after  which  steam  under  pressure 

53 


54  PRACTICAL   SANITATION. 

is  turned  in  and  the  apparatus  maintained  for  10  minutes  at  a 
pressure  of  10  lbs.  to  the  square  inch.  If  the  preliminary  vacuum 
is  not  used,  the  treatment  is  maintained  for  20  minutes  at  a  pres- 
sure of  15  lbs. 

This  is  particularly  valuable  in  ship  and  car  disinfection,  when 
large  quantities  of  bedding  and  immigrants'  clothing  must  be 
handled,  as  it  not  only  disinfects,  but  kills  all  vermin.  The  main 
objection  to  the  process  is  that  it  shrinks  wool  fabrics  badly. 

Boiling. — The  articles  are  dropped  into  a  vessel  of  water  which 

is  boiling  strongly.     It  is  applicable  to  white  goods,  metal  articles, 

table  ware,  and  bedding  (except  wool  blankets  and  pillows).     The 

addition  of  a  teaspoonful  of  baking  soda  to  each  pint  of  water 

makes  the  action  more  certain.     After  coming  to  the  boil  again, 

the  temperature  should  be  maintained  at  that  point  for  30  minutes 

at  low  and  moderate  altitudes,  but  high  in  the  mountains  must  be 

\       correspondingly  increased.     A  fair  rough  test  would  be  to  place 

\      a  moderate  sized  potato  in  the  boiler  with  the  goods,  and  when 

\     the  potato  is  done,  the  disinfection  is  complete. 

Streaming  Steam. — For  disinfection  by  streaming  steam,  an  ap- 
paratus may  be  improvised  consisting  of  a  large  wash-boiler  with 
two  bricks  set  on  edge  in  the  bottom,  and  short  boards  resting  on 
them.  A  couple  of  inches  of  water  is  then  placed  in  the  bottom  of 
the  boiler,  the  infected  articles  are  packed  in  loosely,  the  cover  is 
put  on,  and  the  apparatus  brought  to  the  boiling  point  and  main- 
tained there  for  an  hour. 

This  method  is  applicable  to  feathers,  plumes,  pillows  and  blan- 
kets, but  presents  no  special  advantages  over  formaldehyd. 

Dry  Heat. — The  use  of  dry  heat  is  hardly  practical  in  sanitary 
I  disinfection,  owing  to  the  risk  of  overheating,  burning  and  scorch- 
I  ing. 

Chemical  Disinfectants. — 'These  are  of  two  classes,  liquid  and 
gaseous.  To  the  first  class  belong  bichloride  of  mercury,  carbolic 
ac^.d,  the  cresols,  bleaching  powder  and  sodium  hypochlorite,  and 
lime,  since  these  are  most  readily  applied  in  solution  or  suspension. 
The  second  class  comprises  formaldehyd,  sulphur,  and  hydrocyanic 
acid,  since  to  be  effective  they  must  be  in  gaseous  form. 

Bichloride  op  Mercury. — This  is  also  known  as  corrosive  subli- 
mate and  mercuric  chloride.  It  is  a  disinfectant  of  great  power  and 
is  applied  in  solutions  of  1 :500,  1  -.1000,  and  1 :2000,  according  to 
the  purpose  for  which  it  is  employed.     It  may  be  made  with  sea 


DISINFECTION.  55 

water,  and  if  made  with  fresh  water  must  have  twice  as  many  parts 
of  common  salt  or  ammonium  chloride  (sal  ammoniac)  added  to 
increase  its  solubility  and  to  interfere  with  the  precipitation  of 
the  bichloride  by  albumins  which  may  be  present.  That  is,  a 
1 :500  solution  requires  4  parts  per  1000  of  salt ;  a  1 :1000,  2  parts, 
and  so  on.  The  efficiency  of  the  disinfection  is  interfered  with  by 
alkalies,  albumins,  and  most  seriously  of  all,  by  sulphur  and  sul- 
phides. 

Bichloride  solutions  attack  most  metals  and  cannot  be  satisfac- 
torily used  on  limed  walls.  They  must  be  made  up  in  a  non- 
metallic  container.  The  1 :500  strength  is  employed  for  feces  and 
sputum,  the  1 :1000  for  walls  and  floors  and  for  clothing,  and  the 
1 :2000  for  the  disinfection  of  the  person. 

Carbolic  Acid.  (Phenol). — In  5  per  cent  solution  this  agent 
is  well  adapted  to  mopping  floors,  side  walls  and  ceilings.  It  is 
cheap,  does  not  affect  metals  or  bright  work,  but  attacks  the  hands 
so  that  it  must  be  applied  with  a  mop  or  spray,  or  the  hands  must 
be  protected  with  rubber  gloves.  With  exposure  for  an  hour  this 
solution  may  be  used  for  stools  and  sputum. 

Cresols. — The  cresols  are  analogues  of  carbolic  acid  and  belong 
to  the  same  phenol  group.  They  are  sold  under  a  variety  of  pro- 
prietary names,  and  are  somewhat  stronger  than  carbolic  acid  in 
disinfecting  power.  A  2  per  cent  solution  is  very  satisfactorily 
:  used  in  the  same  way  and  for  the  same  purposes  as  the  carbolic 
\  acid  solution  just  mentioned.  In  this  strength  it  is  not  hard  on 
\  the  hands.  An  ordinary  garden  spray  will  be  found  very  useful  for 
applying  this  fluid  to  walls  and  ceilings. 

Formalin. — This  is  a  40  per  cent  formaldehyd  solution  nomi- 
nally, and  actually  contains  from  2  per  cent  to  10  per  cent  less  of 
the  gas  owing  to  volatilization,  polymerization  or  faulty  manu- 
facture. It  may  be  diluted  with  19  parts  of  water  for  use  on  floors 
and  walls,  and  stools  or  sputum  will  be  innocuous  after  being  ex- 
posed to  its  action  in  this  strength  for  one  hour.  Ammonia  inter- 
feres with  its  action,  but  albumin  does  not.  It  irritates  eyes  and 
nose  strongly. 

Chloride  of  Lime.  (Bleaching  Powder). — This  must  be  of  the 
best  quality  or  it  is  worthless.  If  freshly  taken  from  a  full  con- 
tainer it  should  be  good.  It  should  have  a  pungent  odor  of  chlorine. 
514  ounces  of  the  powder  are  dissolved  in'^a  gallon  of  water,  as 
pure  and  cold  as  possible.     Chamber  vessels  and  sputum  cups  are 


56  PRACTICAL  SANITATION. 

partly  filled  with  the  solution  before  use,  and  the  discharges  are 
allowed  to  stand  at  least  30  minutes  before  emptying  into  the  vault 
or  water  closet.  Except  that  it  is  a  somewhat  better  deodorant, 
it  has  no  particular  advantages  over  the  solutions  already  named, 
any  of  which  may  be  used  for  this  purpose,  all  being  equally  worth- 
less unless  properly  mixed  with  the  infected  material  and  allowed 
to  stand  for  a  sufficient  time.  Chloride  of  lime  solution  bleaches 
most  colored  materials  and  corrodes  metals,  so  must  be  used  with  . 
caution. 

Lime. — This  is  one  of  the  most  valuable  outdoor  disinfectants. 
In  powder  it  rapidly  absorbs  moisture  and  carbonic  acid  from  the 
air,  so  that  it  must  be  freshly  burned  to  be  of  value.  As  white- 
wash it  furnishes  a  clean  background  against  which  dirt  is  readily 
perceptible,  and  entangles  and  destroys  any  microbes  present.  As 
a  disinfectant  it  is  used  in  the  form  of  milk  of  lime  which  is  made 
in  the  following  manner;  one  quart  of  small  pieces  of  quicklime 
is  added  to  II/2  pints  of  water.  This  makes  a  dry  hydrate  of  lime 
in  powder.  One  pint  of  this  powder  is  added  to  a  gallon  of  water, 
and  the  resulting  milk  of  lime  may  be  used  to  disinfect  stools  and 
should  be  habitually  employed  in  outhouses.  If  kept  from  contact 
with  the  air,  this  solution  will  keep  a  few  days,  and  the  hydrate  will 
keep  a  week  or  two.  This  is  the  cheapest  of  disinfectants,  an 
effective  deodorant,  and  should  be  freely  used  on  putrefying  or 
putrescible  matter  of  any  kind. 

Sulphate  of  Iron.  {Green  Vitriol). — This  was  formerly  em- 
ployed for  the  disinfection  of  outhouses  and  cess-pools,  but  recent 
investigations  throw  much  doubt  on  its  efficiency.  It  is  not  recom- 
mended. 

FUMIGATION. 

In  order  to  disinfect  successfully  by  fumigation  certain  precau- 
tions are  to  be  observed.  The  room  or  building  must  be  tight,  and 
if  not  naturally  so  must  be  made  so  by  pasting  paper  strips  over 
all  outlets  from  the  area  undergoing  disinfection.  Cracks  under 
doors  must  be  pasted  over  or  chinked  with  rags.  The  atmosphere 
must  be  made  both  warm  and  damp.  Good  disinfection  cannot  be 
done  mth  a  temperature  below  60°  or  an  atmosphere  less  than  60 
per  cent  saturated  with  moisture.  This  moisture  may  be  natural 
on  damp  days,  but  in  bright  weather  it  must  be  augmented  by  boil- 
ing water  on  a  stove,  by  pouring  water  (preferably  hot)  on  to  hot 


DISINFECTION.  57 

bricks  or  stones,  or  by  slaking  lime.  It  is  best  to  do  this  before 
beginning-  the  disinfection  proper  in  order  that  the  moisture  may 
have  time  to  penetrate  everywhere. 

Since  both  formaldehyd  and  sulphur  fumes  are  deficient  in  pene- 
trating power,  drawers  and  closets  are  opened  up,  beds  unmade 
and  everything  spread  as  loosely  as  possible  on  chairs,  lines  and 
other  supports.  Books  are  spread  with  leaves  and  covers  separated 
and  set  on  end.     If  of  little  value  they  are  best  destroyed. 

As  a  check  on  the  efficiency  of  the  disinfection,  threads  inoculated 
with  easily  identified  resistant  forms  of  bacteria,  may  be  placed 
at  various  points  and  cultures  made  after  the  conclusion  of  the 
work  will  show  whether  the  work  has  been  thoroughly  done  or 
not.  This  check  is  particularly  valuable  if  one  cannot  attend  to 
the  disinfection  in  person. 

After  disinfection  by  either  of  the  above  methods,  if  the  weather 
permits,  the  entire  contents  of  the  room  should  be  put  outside  to 
air  and  sun.  If  the  weather  is  bad,  the  fumigated  materials  may 
be  transferred  to  any  convenient  room  while  the  second  step  of 
disinfection  is  undergone,  which  is  the  washing  of  floors  and  mop- 
ping or  spraying  of  walls  vsdth  one  of  the  liquid  disinfectants  de- 
scribed previously — preferably  bichloride,  carbolic  acid  or  cresol 
solution.  These  are  non-volatile  and  remain  in  cracks  and  crevices 
for  a  long  time,  becoming  more  concentrated  by  evaporation  of 
water. 

Unit  of  Fumigation. — The  unit  employed  in  all  fumigation  is 
the  amount  of  disinfectant  required  for  1,000  cubic  feet,  and  is 
obtained  by  multiplying  ceiling  height  by  the  length  of  the  room 
and  the  result  by  the  breadth,  and  pointing  off  three  places  from 
the  right.  The  figures  on  the  left  of  the  decimal  point  will  give 
the  number  of  units.  If  the  decimal  is  less  than  .750  and  more  than 
.250,  a  half  unit  additional  should  be  added,  otherwise  the  nearest 
whole  unit  is  used.  For  example,  a  room  24  x  15  with  an  11-foot 
ceiling  has  a  cubical  content  of  3,960  feet,  and  3.960  units  of  the 
disinfectant  will  be  required,  but  under  the  rule  4  units  should 
be  used.  A  room  of  3,190  cubic  feet  would  employ  only  3  units  of 
the  agent,  while  one  of  3,350  would  require  3i^  units. 

A  method  of  computation  which  is  not  yet  legalized,  but  entirely 
rational  and  also  perfectly  safe  if  silk  test-threads  are  used,  is  to 
regard  the  disinfecting  power  >0f  the  gas  used  as  proportional,  not 
to  the  cubic  contents  of  the  room,  but  to  the  area  of  the  walls, 


58  PRACTICAL  SANITATION. 

floor  and  ceiling.  On  this  theory  a  room  of  10  feet  cube,  containing 
1,000  cubic  feet  and  having  600  square  feet  of  exposed  surface, 
requires  one  unit  of  the  disinfectant  gas,  while  a  room  20  feet 
square  and  10  feet  high,  containing  4,000  cubic  feet,  and  presenting 
1,600  square  feet  of  surface,  requires  a  little  less  than  3  units 
instead  of  4  as  would  be  required  by  the  first  rule.  It  is  based 
on  the  theory  that  the  disinfectant  gases  do  not  become  neutralized 
or  fixed  in  the  free  air,  but  only  on  the  surface  of  objects.  This 
same  theory  requires  also  that  if  a  room  contains  a  great  deal  of 
furniture,  bedding'  and  clothing  beyond  the  average,  that  the 
charge  of  the  disinfectant  be  proportionately  increased.  The  ad- 
vantage of  this  method  of  computation  is  the  saving  of  expense 
for  materials,  which  increases  with  the  cubic  contents  of  the  space 
to  be  disinfected. 

Expense. — Used  in  the  quantities  here  recommended,  the  ex- 
pense of  fumigation  with  sulphur  is  about  twenty-five  cents  per 
1,000  cubic  feet;  with  formalin  and  permanganate,  thirty-five  to 
fifty  cents;  with  solidified  formaldehyd  in  large  units,  from  ten 
to  fifteen  cents.  These  figures  are  for  material  alone  without  con- 
sidering cost  of  labor.  The  last  method  is  not  only  cheaper,  but 
more  convenient  and  equally  effective.  If  the  apparatus  allows 
the  vaporization  of  water  along  with  the  paraform,  it  will  also  be 
more  penetrating. 

Sulphur  Fumigation. — This  is  a  very  ancient  method  of  fumi- 
gation, its  use  extending  at  least  as  far  back  as  the  Middle  Ages. 
The  fumes  lack  in  penetration,  so  that  the  opening  up  of  the  ma- 
terials to  be  disinfected  must  be  very  carefully  done.  Sulphur 
dioxide,  which  is  formed  by  the  combustion  of  sulphur  in  the  air, 
blackens  metals  and  bleaches  colored  fabrics  badly.  It  is  more 
trouble  to  use  than  formaldehyd,  Jjut  is  cheaper  and  has  the  addi- 
tional  advantage  of  killing  vermin  of  all  kinds.  For  these  reasons 
it  is  preferable  for  disinfecting  schools,  vessels,  freight  cars,  and 
public  buildings,  where  the  contents  are  of  a  character  not  likely 
to  be  injured  by  the  fumes. 

To  secure  efficient  disinfection  with  sulphur  it  is  necessary  to 
have  the  atmosphere  4.5  per  cent  saturated,  which  is  secured  by 
burning  5  lbs.  of  sulphur  and  the  evaporation  of  1  pint  of  water 
for  each  1,000  cubic  feet  of  space  to  be  disinfected.  The  room  must 
be  made  absolutely  tight  as  sulphur  works  rather  slowly,  and  any 
leakage  will  reduce  the  percentage  of  gas  below  the  allowable  limit. 


DISINFECTION.  59 

The  sulphur  should  be  finely  powdered,  as  roll  sulphur  is  less 
combustible,  goes  out  badly  and  leaves  much  residue.  It  should 
be  burned  in  shallow  iron  pots  or  Dutch  ovens,  which  are  placed 
in  tubs  of  water  and  covered  "with  wire  screens  to  catch  any  of  the 
burning  sulphur  which  may  pop  out.  Not  more  than  30  lbs.  should 
be  placed  in  any  one  burner  and  better  only  5  to  10  lbs.  The 
sulphur  is  best  fired  by  pouring  on  a  little  wood  alcohol  and  light- 
ing with  a  match.  Twenty-four  hours  are  reciuired  to  kill  the  more 
resistant  bacteria,  but  mosquitoes  and  other  vermin  are  killed  in 
from  two  to  four  hours. 

Formaldehyd  Fumigation. — Formaldehyd  has  come  of  late  years 
to  be  the  disinfectant  of  choice  for  use  by  fumigation.  Many 
methods  are  in  use,  some  of  which  require  complicated  apparatus. 
Of  these  but  three  will  be  described.  The  health  officer  desiring 
to  investigate  any  of  the  others  will  find  them  fully  described  in 
the  publications  of  the  Public  Health  Service.  FormaldehydLhy 
any  method  does  not  tarnish  metals,  fad^  or  turn  g^Jors.  It  does 
noTlcill  vermin  or  mosquitoes,  and  must  never  he  employed  for~ 
such  ajDitrpose^  but  the  addition  of  %  ounce  of  camphor  per XoITO 
cubic  feet  to  a  solid  formaldehyd  disinfection,  will  kill  insects. 

Spraying. — By  this  method,  the  formaldehyd  in  40  per  cent  so- 
lution is  sprayed  with  the  finest  nozzle  of  a  garden  spray-pump  on 
sheets  hung  about  the  room.  This  must  be  done  as  evenly  as  pos- 
sible, so  that  the  drops  do  not  run  or  coalesce.  An  ordinary  large 
sheet  will  hold  about  5  oz.  or  a  little  more,  and  two  sheets  and 
10  oz.  of  the  solution  will  be  required  per  1,000  cubic  feet.  This 
process  cannot  be  relied  on  below  a  temperature  of  72°  on  account 
of  the  formation  of  the  polymeric  body  paraform.  The  sealing 
of  the  room  must  be  done  with  great  care,  the  exposure  continued 
for  12  hours,  and  not  over  2,000  cubic  feet  disinfected  in  one 
body. 

Permanganate  Method. — In  this  process  the  formaldehyd  is 
poured  over  potassium  permanganate  crystals,  in  the  proportion  of 
1  qt.  of  the  former  to  1  lb.  of  the  latter.  CAUTION!  If  the  per- 
manganate is  thrown  into  the  formalin,  it  m/iy  explode.  In  most 
of  the  states  this  amount  is  required  for  1,000  cubic  feet,  but  the 
Public  Health  Service  allows  this  amount  for  2,000  cubic  feet  and 
if  the  temperature  is  above  60°  permits  the  use  of  only  10  oz.  of 
formalin  and  5  oz.  of  permanganate. 

When  the  reagents  above  mentioned  are  mixed,  a  violent  effer- 


60 


PRACTICAL   SANITATION. 


vescence  takes  place  and  almost  the  whole  of  the  contained  formal- 
dehyd  is  set  free  within  a  very  few  minutes.  This  gas  is  very 
dry  and  highly  inflammable,  and  naked  flames  or  fire  of  any  kind 
must  be  kept  away  for  fear  of  explosions.  The  residue  left  at  the 
close  of  the  reaction  is  a  nearly  dry  mass  when  the  reagents  are 
of  good  quality.  At  least  4  hours'  exposure  are  required  for  ef- 
fective disinfection  by  this  means. 

Paraform. — "Solid  Formaldehyd. "  The  use  of  paraform — 
the  solid  polymer  of  formaldehyd — by  heating  over  specially  con- 
structed lamps  has  met  with  favor.  Used  with  moisture  in  the 
proportion  of  1  oz.  per  1,000  cubic  feet  it  is  very  convenient  and 


Fig.   1. — Types  of  generators  for  disinfection  with  solid  formaldehyd   (Paraform). 

effective.  The  candles  with  wicks  running  down  through  the  para- 
form are  not  to  be  recommended  since  too  large  a  proportion  of  the 
gas  is  burned  in  the  process  of  volatilization.  Still  less  are  the 
compound  candles  of  paraform  and  sulphur  to  be  approved,  as 
the  products  of  sulphur  combustion  unite  with  the  formaldehyd  and 
consequently  neither  portion  is  of  value. 

Hydrocyanic  Acid. — "Prussic  acid."  This  is  not  properly 
speaking  a  disinfectant,  but  is  the  most  certain  and  deadly  of 
poisons  to  all  animal  life.  It  destroys  infallibly  all  kinds  of  ver- 
min, but  is  on  no  account  to  he  used  without  every  precaution, 
since  it  is  almost  instantaneously  fatal  to  human  life.     Plence,  no 


DISINFECTION.  61 

one  can  remain  in  a  house  where  it  is  being  used,  and  sufficient 
ventilation  must  be  left  to  allow  the  air  to  be  completely  changed 
in  say  6  hours.  These  ventilators  must  be  protected  from  incau- 
tious approach,  since  fatal  poisoning  might  occur  from  going  too 
near  them. 

It  is  only  justified  for  use  in  case  of  typhus  or  plague  where  lice 
or  rats  are  presumed  to  be  concealed  in  places  where  sulphur  can- 
not readily  reach.  In  the  hands  of  experts  it  may  be  used  to 
destroy  mosquitoes  in  living  quarters,  or  rats  and  weevils  in  mills 
and  elevators,  but  is  hardly  justifiable  for  such  purposes  in  the 
hands  of  the  inexperienced. 

For  each  1,000  cubic  feet  the  following  are  required: 

Potassium  cyanide   10  oz. 

Sulphuric   acid    15  oz. 

Water    23  oz. 

The  sulphuric  acid  is  added  slowly  to  the  water  in  some  vessel 
which  can  stand  the  heat.  The  cyanide,  either  potassium  or  sodium, 
should  be  of  the  best  quality  and  as  free  as  possible  from  impuri- 
ties, especially  sodium  chloride,  which  decomposes  the  cyanide  in 
the  presence  of  water.  It  is  weighed  into  bags,  which  are  best  made 
of  close  white  muslin,  but  may  be  of  paper.  If  of  paper,  they 
should  be  slightly  torn  before  dropping  into  the  acid.  The  acid  is 
then  placed  in  large  crocks  or  earthen  jars  which  are  distributed  to 
the  best  advantage  throughout  the  building  or  vessel.  Both  acid 
and  cyanide  should  be  proportioned  accurately  to  the  size  of  the 
space  to  be  fumigated,  on  account  of  the  expense  of  the  materials. 
The  operator  then  drops  the  sacks  into  the  acid  and  escapes  quickly, 
closing  the  door  after  him. 

As  hydrocyanic  acid  is  lighter  than  air,  this  method  is  not  adapted 
to  fumigating  the  holds  of  ships,  and  a  method  employing  barrels 
is  in  use.  In  large  water-tight  barrels  is  placed  the  proper  quan- 
tity of  acid  to  be  used,  the  acid  being  freshly  diluted  in  order  to 
retain  the  heat,  and  the  proportional  amount  of  cyanide  in  solu- 
tion is  run  into  them  through  ordinary  garden  hose  and  a  funnel 
from  the  deck.  To  neutralize  the  residual  acid  and  expel  the  re- 
maining gas  rapidly,  a  saturated  solution  of  sodium  carbonate  is 
run  into  the  barrel  after  a  lapse  of  a  few  seconds.  This  also  makes 
a  gas  mixture  whicl^  is  heavier  than  air,  and  secures  a  better  dif- 
fusion. About  half  as  much  sodium  carbonate  as  cyanide  should 
be  used. 


62  PRACTICAL   SANITATION. 

Responsibility. — The  responsibility  for  proper_ disinfection  rests 
on  thp  health  officer^  and  if  he  cannot  do  it  himself,  he  should  see 
that  only  reliable  persons  do  it  for  him.     The  work  should  be 

checked  by  the  use  of  infected  threads  as  mentioned  earlier  in  this 
chapter.  Care  should  be  taken,  not  onr^_that  disease  germs  ar,e 
destroyed,^  but  that  property  is  not  damaged  by  fire  or  chemical 
fumes,  as  sur^  either  against  the  health  officer  or  the  municipality 
may'follow,  and  even  if  they  do  not,  a  prejudice  is  created  which 
is  entirely  unnecessary. 

Expense. — The  expense  of  disinfection  is  varionsly  ta^ed.     In 

f^jn^  pontes  ^^  ^"^  plnnnrl   nty^jnsl-  fliA  hn^-|^phn1dpr^   anrl  in   his-d<A>-u44!-' 

against  the  property  disinfected.  Jn  other  states  it  is  more  pron- 
erly  paid  by  the  municipality.  This  is  the  better  and  wiser  plan, 
as-ihCT^is  not  the  temptation  to  hide  disease  to  escape  expense  as 
well  as  the  inconvenience  of  quarantine.  It  is  no  more  reasonable 
to  expect  a  man  to  pay  for  the  disinfection  of  his  house  after  an 
infectious  disease  than  it  is  to  ask  him  to  pay  for  the  apprehension 
of  the  burglar  who  has  robbed  him  or  the  murderer  who  has  killed 
a  member  of  his  family. 


CHAPTER  VI. 
THE  TYPHOID  GROUP. 

Thf^  nhara.f^t.pristif^s  nf  tin's  fyronp  arp  rlistnrhanpps  nf  thp  fyflstrn- 
inltestinal  tracts  as  diarrhea  and  vomiting^.  Infection  is  taken  in 
practically  phygjsjjy  the  m^ntlv  It  may  be  by  contact,  mediate 
or  immediate  in  which  excreta  bearing  the  specific  micro-organisms 
are  conveyed  to  the  patient's  month  by  unwashed  hands,  in  food 
or  drink  infected  by  carelessness  in  handling  these  excreta,  by 
carriers,  or  by  flies  and  dust. 

In  the  investigation  of  outbreaks  of  these  diseases  in  the  country 
or  small  towns,  the  water  supply  is  first  to  be  suspected;  then  im- 
proper disposal  of  excreta ;  the  food  supply,  including  milk ;  flies 
and  dust.  Human  carriers  play  a  considerable  part,  which  is  prob- 
ably more  important  in  the  city  than  in  the  country,  in  proportion 
to  the  total  number  of  cases.  In  cities  having  a  proper  sewage 
disposal,  flies  and  dust  can  almost  be  eliminated,  while  in  tem- 
porary communities  such  as  railroad  camps  they  play  a  large  part, 
and  in  small  permanent  communities  should  always  be  taken  into 
account. 

It  should  not  be  forgotten  that  in  considerable  epidemics  all  of 
these  causes  may  be  and  usually  are  operative,  especially  in  typhoid, 
paratyphoid  and  Asiatic  cholera. 

The  feces  and  urine  are  the  channels  for  the  perpetuation  of  the 
infection,  and  must  always  be  carefully  disinfected  before  putting 
them  into  the  closet  or  sewer. 

TYPHOID  FEVER. 

Synonyms. — Enteric  fever;  abdominal  typhus;  autumnal  fever; 
' '  Typho-malarial  fever. ' ' 

Distribution. — Endemic  everywhere,  becoming  epidemic  at  times. 

Etiology. — Infection    by    and    growth    of    Bacillus     typhosus 

-JEberth).     This  micro-organism  is  1  mi.  in  width  and  3  mi.  in 

leng-th,  varying  somewhat  with  cultural  conditions;   stains  with 

watery  methyl  blue,  but  not  by  Gram's  method;  resists  moist  heat 

63 


64  PRACTICAL   SANITATION. 

np  to  156°F  (69° C)  ;  lives  three  months  in  distilled  water  and  6 
months  in  moist  earth ;  withstands  repeated  freezing  and  thawing ; 
is  killed  by  6  hours  .of  direct  sunlight,  0.5  per  cent  phenol  and 
1 :5000  bichloride  solution.  It  must  be  taken  into  the  alimentary 
canal  to  produce  infection,  and  in  the  so-called  "Typhoid  carriers" 
may  remain  there  for  years,  being  transferred  by  their  dirty  hands 
to  the  food  and  drink  of  others,  thus  causing  new  cases.  Milk  and 
water  are  frequent  sources  of  infection,  and  green  vegetables  which 
have  been  contaminated  by  sewage  are  other  important  sources. 
The  common  house  fly  is  extremely  dangerous  in  the  direct  carrying 
of  typhoid  discharges  to  food  and  drink,  especially  in  localities 
mthout  sanitary  sewers.  Dust  may  be  a  conveyor,  either  by  inha- 
lation or  ingestion. 

Pathology. — Anatomically  characterized  by  hyperplasia  and  ul- 
ceration of  the  lymph  follicles  of  the  small  intestine  and  mesentery, 
and  enlargement  of  the  spleen,  these  organs  containing  great  num- 
bers of  the  bacilli.  Bacilli  are  commonly  found  in  the  blood  stream, 
and  have  been  found  as  single  foci  in  almost  every  organ  of  the 
body.     The  urine  and  feces  are  loaded  with  bacilli. 

Predisposing  Factors. — Age  below  30 ;  male  sex ;  epidemics  most 
common  in  late  summer  or  autumn. 

Incubation. — One  to  two  or  more  weeks. 

Prodromes. — Malaise ;  loss  of  appetite ;  slightly  coated  tongue. 

Symptoms. — In  children,  attack  may  begin  with  headache,  nausea, 
chilliness  and  furred  tongue.  At  all  ages  there  may  be  nosebleed; 
looseness  of  bowels;  ''Stairstep"  temperature  curve;  pulse  usually 
moderate;  rose  spots  on  abdomen  and  sometimes  on  other  parts  of 
body,  disappearing  on  pressure;  "Pea  soup"  stools  of  clay  color. 
These  symptoms  are  common  but  not  invariable.  More  rare  are 
petechias,  sudamina  and  vibiae;  hemorrhage  of  the  bowels  is  fre- 
quent, as  is  gurgling  in  the  right  iliac  region.  Delirium,  tremor 
and  hiccoughs  are  often  seen  late  in  the  disease.  Hemoglobin  is 
always  diminished,  and  the  leucocytes,  normal  in  number  at  first, 
are  diminished  slightly  and  gradually  through  the  course  of  the 
disease,  not  becoming  normal  until  some  time  after  convalescence 
is  established.  Eelapses  are  common  in  this  disease  and  may  be 
multiple. 

Diagnosis. — Clinically  this  disease  may  usually  be  diagnosed  by 
the  signs  and  symptoms  above  enumerated;  the  diazo  reaction  of 
the  urine  is  of  some  value,  but  the  serum  (agglutinin)  reaction  of 


THE    TYPHOID    GROUP.  '        65 

Widal  and  Gruber  is  with  proper  technique  and  exclusion  of  a 
recently  preceding  attack  of  typhoid,  or  recent  immunization  by 
typhoid  bacterin,  almost  absolutely  diagnostic  if  positive,  and  should 
be  found  in  70  per  cent  during  the  first  week,  80  per  cent  during 
the  second  and  90  per  cent  during  the  following  two  weeks.  The 
blood  culture  is  much  more  reliable  than  either  of  the  above  and 
is  to  be  found  in  95  per  cent  of  all  cases  during  the  first  week.  It 
is  perfectly  feasible  for  any  well  equipped  municipal  laboratory. 
(See  Part  III  for  diazo  and  agglutinin  reactions.) 

Differentiation. — Differentiate  from  paratyphoid;  estivo-au- 
tumnal  fever ;  acute  miliary  tuberculosis ;  cerebrospinal  meningitis ; 
pneumonia ;  concealed  suppuration. 

Sequelae. — Cholecystitis;  gall-stones;  "Milk  leg";  "Typhoid 
spine";  neuritis;  nephritis,  rarely;  bone  lesions,  commonly. 

Termination. — After  4  weeks  in  uncomplicated  cases,  the  tem- 
perature usually  declining  regularly  and  gradually.  In  fatal  cases 
the  cause  of  death  may  be  exhaustion,  toxemia,  syncope,  hemor- 
rhage, or  perforation  of  the  bowel  and  consequent  peritonitis. 

Immunity. — Second  attacks  occasionally  occur. 

Prognosis. — 'The  mortality  in  private  practice  with  family  nurs- 
ing is  20  per  cent  and  with  skilled  nursing  is  10  per  cent  (Tyson). 
With  full  cold  bath  treatment  Osier  and  Tyson  each  report  7.3  per 
cent.  The  mortality  from  18  to  22  and  after  40  seems  to  be  higher 
than  at  other  ages,  and  pregnancy  adds  a  great  additional  risk,  as 
abortion  usually  takes  place  in  the  second  week  of  the  disease. 

Quarantine. — In  civil  practice,  none;  in  camp  practice,  such  as 
railroad  construction  and  other  public  works,  if  possible,  the  pa- 
tient should  be  removed  to  a  special  hospital  at  a  distance  from  the 
work. 

Individual  Prophylaxis. — Boil  water;  screen  all  food  from  flies 
and  protect  from  dust.  If  nursing  a  patient,  disinfect  hands  with 
soap  and  water  followed  by  an  antiseptic  wash.  Pay  attention  to 
the  condition  of  stomach  and  bowels.  Protective  inoculation  by 
Sir  A.  E.  Wright's  method  is  of  the  greatest  value  for  professional 
nurses  and  travelers  who  are  likely  to  be  exposed  to  typhoid. 

This  vaccine  is  prepared  commercially  by  several  of  the  large 
manufacturers  of  biological  products  and  is  also  to  be  had  free 
from  some  of  the  state  laboratories.  It  is  prepared  by  suspending 
killed  typhoid  bacilli  in  physiological  salt  solution,  and  is  usually 
standardized  at  1,000,000,000  per  c.c.     The  first  dose  is  one-half 


66  PRACTICAL   SANITATION. 

that  amount ;  the  second,  on  the  eighth  day,  is  the  full  dose  of  1  e.e. ; 
and  the  third,  on  the  fifteenth  day,  is  the  same  as  the  second. 

To  administer  this  vaccine  the  hypodermic  syringe  and  needle 
are  carefully  boiled,  the  ampoule  containing  the  vaccine  is  opened, 
the  needle  placed  in  it,  and  the  syringe  filled  and  emptied  several 
times  in  order  that  the  suspension  may  be  as  uniform  as  possible. 
In  the  meantime  the  arm,  witJiout  previous  washing,  has  been 
painted  with  tincture  of  iodine  to  a  deep  brown  color  over  an  area 
of  2  inches  in  diameter.  The  needle  is  introduced  only  into  the 
subcutaneous  tissues;  not  into  the  fascia  or  muscle.  The  punc- 
ture is  sealed  with  collodion. 

There  is  generally  some  reaction  following  the  first  dose,  but  this 
is  seldom  severe  and  rarely  consists  of  more  than  slight  chilly  sen- 
sations followed  by  a  rise  of  temperature  of  a  degree  or  two.  There 
may  also  be  a  slight  local  reaction,  with  swelling  of  the  axillary 
glands  for  a  day  or  two. 

This  has  been  largely  used  in  military  practice  and  reduces  the 
incidence  from  typhoid  fever  to  almost  nothing.  The  immunity 
lasts  for  several  years  at  least,  but  the  point  of  loss  of  immunity 
is  not  known.  Persons  who  have  had  this  treatment  give  the 
Widal  reaction,  and  in  case  of  doubtful  diagnosis  of  any  fever  in 
a  person  so  immunized,  a  blood  culture  is  necessary, 

Typhoidin  Reaction. — A  minute  quantity  of  typhoid  toxins  in- 
jected into  the  deeper  layers  of  the  skin  is  followed  in  about  24 
hours  by  an  area  of  hyperemia  which  is  more  intense  in  direct 
ratio  to  the  completeness  of  natural  or  acquired  immunity.  A  nega- 
tive reaction  shows  that  the  immunity,  whether  natural  or  acquired, 
has  lapsed. 

Community  Prophylaxis. — All  bodily  discharges  from  the  pa- 
tient must  be  disinfected  with  a  standard  disinfectant.  Make  a 
thorough  search  for  any  water  or  milk  supply  that  may  possibly  be 
contaminated.  If  any  other  source  of  water  supply  is  available, 
condemn  the  one  at  fault;  if  not,  boil  water  for  20  minutes  and 
preferably,  filter  and  aerate.  Eliminate  all  sources  of  contamina- 
tion to  water.  If  a  public  supply  such  as  a  reservoir  is  infected, 
install  filter  beds;  if  these  are  already  in  use,  they  must  be  re- 
modeled or  renovated  under  the  supervision  of  a  competent  sanitary 
engineer.  In  addition  the  filtered  water  should  be  treated  by  some 
such  method  as  the  hypochlorite  if  possible.  If  a  well  is  at  fault  it 
can  be  made  safe  by  disinfection.     A  cistern  may  always  be  disin- 


THE   TYPHOID    GROUP.  67 

feeted.  If  it  is  desired  to  destroy  a  well  it  may  be  done  by  throwing 
in  kerosene  and  thus  making  the  water  permanently  unpotable,  but 
leaving  it  as  good  as  before  for  washing  clothing. 

Seek  out  carriers  and  have  them  taken  from  handling  food  sup- 
plies. Carriers  are  more  readily  found  by  the  agglutinin  (Widal) 
reaction  than  by  plating  the  stools,  and  this  should  never  be  omitted 
in  looking  for  carriers.  If  the  reaction  is  positive  the  stools  are 
plated,  and  the  matter  may  be  definitely  settled. 

Stools  and  urine  of  typhoid  patients  must  be  disinfected  with  a 
standard  disinfectant  (see  Disinfectants),  exposing  the  excreta  to 
the  action  of  the  disinfectant  for  at  least  one  hour  before  throwing 
into  the  closet  or  vault.  Soiled  linen  or  clothing  must  be  kept  pro- 
tected from  flies,  and  boiled,  or  sprinkled  with  40  per  cent  for- 
maldehyd  solution  and  left  rolled  up  in  a  tight  container  for  at 
least  6  hours  before  sending  to  the  laundry.  Screens,  fly  paper 
and  fly  poison  together  with  destruction  of  all  possible  breeding 
places,  must  be  used  to  keep  flies  out  of  the  sick  room  and  away 
from  infected  material. 

Disinfection. — Disinfect  by  scrubbing  the  walls  and  woodwork 
of  the  sick  room  with  soap  and  water  and  afterwards  with  a  standard 
disinfectant.  Fumigation  is  required  by  some  states,  but  is  prob- 
ably not  necessary. 

PARATYPHOID  FEVER. 

Etiology. — This  diseage  is  caused  by  a  hncillup!  nr  a^roup  of  ba,- 
cilli,   intermediate   in   character  hptwppn   thp   typhoid   and   colon 

^OU£S. 

Dis^ibution. — Sporadic  everywhere;  occasionally  becoming  epi- 
demic. 

Pathology. — Spleen  enlarged ;  intestine  sometimes  ulcerated,  but 
the  ulcers  resemble  those  of  dysentery  rather  than  those  of  typhoid ; 
Peyer's  patches  are  not  ulcerated.  Focal  necroses  have  been  found 
in  the  liver.  The  lesions  are  in  general  those  of  septicemia  and 
not  those  of  typhoid. 

Symptoms. — ^Typhoid  in  character,  milder  in  course,  and  of  bet- 
ter prognosis.  Diarrhea  and  termination  by  crisis  are  more  common 
than  in  typhoid.  Muscular  inflammation  and  joint  abscesses  are 
complications  very  rare  in  typhoid  and  observed  with  some  fre- 
quency in  paratyphoid.  Many  cases  of  food  poisoning,  particularly 
sausage  poisoning,  are  now  believed  to  be  due  to  B.  paratypJioideus 


68  PRACTICAL   SANITATION. 

or  its  toxic  products,  so  that  the  familiar  symptoms  of  food  poison- 
ing; should  probably  be  added  to  the  above. 

Diagnosis. — Negative  agglutination  with  the  Bacillus  typhosus, 
and  a  positive  reaction  with  the  paratyphoid  bacilli. 

Prognosis. — Better  than  that  of  typhoid,  but  no  exact  statistics 
either  of  mortality  or  morbidity  are  available. 

Prophylaxis. — In  all  particulars  the  same  as  typhoid. 

MOUNTAIN  FEVER. 

A  true  typhoid,  as  shown  by  the  serum  reactions,  and  from  the 
standpoint  of  the  sanitarian  to  be  treated  in  all  respects  as  such. 
It  must  not  be  confounded  with  tick  fever. 

AMEBIC  DYSENTERY.  < 

Synonyms.— " Flux ";  "Bloody  Flux." 

Definition. — An  acute  or  chronic  inflammation  of  the  large  intes- 
tine, caused  by  infection  with  the  Entameba  histolytica. 

Distribution. — In  all  tropical  countries,  and  over  the  entire 
United  States. 

Etiology. — The  organism  is  taken  in  with  contaminated  water 
or  food,  the  most  frequently  infected  food  being  salad  vegetables 
eaten  raw.  Entameha  histolytica  is  from  15  to  20  mi.  in  diameter 
and  consists  of  a  clear  outer  zone  (ectosarc),  and  a  granular  inner 
zone  (endosarc),  and  contains  a  nucleus  and  one  or  two  vacuoles. 
The  movements  of  this  organism  resemble  those  of  the  ordinary 
Ameba,  and  consist  of  slight  projections  or  retractions  of  the  pro- 
toplasm. They  frequently  contain  red  blood  cells  which  they  have 
taken  in.  They  are  easily  to  be  recognized  in  the  tissue  by  proper 
stains,  and  may  be  in  enormous  numbers.  They  can  be  recovered 
from  the  pus  of  liver  abscess  following  dysentery.  Entameha  his- 
tolytica has  been  cultivated  by  a  number  of  men,  but  with  some 
difficulty,  and  it  seems  that  certain  bacteria  are  necessary  to  suc- 
cessful growth.  It  has  an  encysted  or  resting  stage  in  which  it 
resists  drying  for  months.  Experiments  by  Stiles  and  Keister  show 
that  the  related  Lamhlia  spores  are  carried  by  flies,  and  presumably 
the  dysentery  infection  may  be  disseminated  by  the  same  agency. 

Pathology. — The  lesions  are  found  in  the  large  intestine,  and 
more  rarely  in  the  lower  part  of  the  ileum.  Abscess  of  the  liver 
is  very  common,  occurring  in  about  20  per  cent  of  the  eases  seen 
in  the  Johns  Hopkins  Hospital. 


THE   TYPHOID    GROUP.  69 

Intestines. — The  lesions  are  ulcers,  preceded  by  an  infiltration  of 
the  submucosa  consisting  of  swelling  of  the  tissue  and  multiplica- 
tion of  its  fixed  cells.  The  mucous  membrane  over  these  areas  soon 
become  necrotic  and  sloughs,  leaving  the  submucous  tissue  as  a  gray- 
ish-yellow gelatinous  mass,  M^hich  is  the  first  floor  of  the  ulcer  but 
later  is  cast  off.  The  ulcers  are  oval,  round  or  irregular,  with 
infiltrated  and  undermined  edges.  The  ulcer  itself  may  be  very 
large  compared  with  the  small  opening  through  the  mucosa.  Any 
of  the  coats  of  the  bowel  except  the  mucosa  may  form  the  floor  of 
the  ulcer  according  to  the  state  at  which  it  is  observed. 

Amebse  may  easily  be  found  infiltrating  the  tissues. 

Liver. — Lesions  in  the  liver  are  of  two  lands ;  a  disseminated 
local  necrosis  of  the  liver  tissue,  and  a  true  abscess  formation. 
Either  type  may  follow  cases  of  dysentery  of  any  grade  of  severity. 
Abscesses  may  rupture  into  the  bowel,  the  peritoneal  cavity  or  the 
pleura,  or  may  become  encysted.  Secondary  infection  with  pus 
organisms  may  take  place. 

Symptoms.— Mild  Form. — Infection  may  be  present  for  a  month 
or  longer  before  symptoms  are  shown,  except  the  most  vague  as 
headache,  lassitude,  slight  pain  in  the  abdomen  and  occasional 
diarrhea. 

Acute  Form. — Pain  and  tenesmus  severe;  blood  and  mucus  are 
found  in  stools  and  later  sloughs  may  be  passed.  In  very  severe 
cases  the  stools  are  passed  every  few  minutes.  The  temperature 
is  ordinarily  not  high,  but  emaciation  may  be  very  rapid,  and  death 
may  occur  in  a  week. 

Chronic  Amebic  Dysentery. — The  disease  may  begin  either  in 
an  acute  or  sub-acute  form,  gradually  passing  into  a  chronic  form, 
the  special  characteristic  of  which  is  the  alternation  of  constipa- 
tion and  diarrhea.  During  the  exacerbations,  the  symptoms  are 
much  the  same  as  in  the  acute  form,  with  pain  in  the  bowels  and 
blood  and  mucus  in  the  stools,  with  slight  fever.  These  attacks 
recur  at  intervals  of  weeks  or  months.  The  patient  often  does 
not  feel  very  ill  and  the  quiescent  periods  allow  some  degree  of 
restoration  of  strength  so  that  emaciation  is  not  so  extreme  as  in 
the  acute  form. 

Diagnosis. — By  the  presence  of  motile  amebse  containing  red 
blood  cells  in  the  stools.  The  specimen  should  be  examined  on  a 
warm  slide. 

Prognosis. — Of  Osier's  cases  23.5  per  cent  died.     The  tendency 


70  PRACTICAL   SANITATION. 

to  relapse  is  very  marked.  Of  his  liver  abscess  cases  19  out  of  27 
died,  and  of  the  operative  liver  abscess  cases  12  out  of  17  died. 

Individual  Prophylaxis. — All  M^ater  should  be  boiled  before 
drinking  and  kept  well  covered  until  used.  Green  vegetables 
should  be  scalded  or  covered  with  strong  vinegar  an  hour  before 
use.  The  hands  should  be  carefully  cleansed  after  contact  with 
the  patient. 

Community  Prophylaxis. — All  bodily  discharges  from  the  pa- 
tient must  be  disinfected  or  destroyed  in  the  same  manner  as  for 
typhoid  fever.  This  disease  is  not  at  present  notifiable,  but  should 
be  made  so  as  it  is  a  really  dangerous  infectious  disease.  Owing  to 
its  wide  distribution  and  the  ease  with  which  one  carelessly  handled 
ease  may  light  up  a  serious  epidemic,  every  precaution  should  be 
observed. 

BACILLARY  DYSENTERY. 

Synonyms.—' '  Flux ";  ''  Bloody  Flux. ' ' 

Definition. — A  form  of  intestinal  flux,  usually  of  an  acute  type, 
occurring  sporadically  and  in  severe  epidemics,  attacking  children 
as  well  as  adults,  characterized  by  pain,  frequent  passage  of  blood 
and  mucus,  and  due  to  the  action  of  a  specific  bacillus  of  which 
there  are  several  strains  (Osier). 

Distribution. — World  wide,  with  high  mortality  everywhere,  but 
especially  in  the  tropics  and  Japan. 

Etiology. — This  disease,  owing  to  improved  sanitation,  is  more 
rare  than  formerly.  It  is  sporadic  during  warm  seasons  every- 
where and  tends  to  become  epidemic  especially  in  crowded  insti- 
tutions.    It  has  been  particularly  fatal  in  military  camps. 

Bacillus  Dysenteric. — This  is  the  specific  morbific  agent.  As 
a  cause  of  dysentery  it  is  approximately  twice  as  frequent  as  the 
amebae.  The  original  form  was  discovered  in  Japan  by  Shiga  in 
1898.  Since  then  at  least  two  other  types  known  as  the  Flexner- 
Harris  type  and  the  "Y"  or  Hiss-Russell  type,  varying  princi- 
pally in  their  sugar-splitting  action,  have  been  isolated.  The 
common  type  in  the  United  States  is  the  Flexner-Harris.  A  serum 
capable  of  agglutinating  one  strain  agglutinates  the  other  two  to 
a  less  degree.  Some  of  the  summer  diarrheas  of  infants  are  due  to 
this  bacillus. 

Incubation. — Not  over  48  hours. 

Symptoms. — The  onset  is  sudden  and  distinguished  by  pain  in 


¥HE   TYPHOID   GROUP.  71 

the  bowels,  slight  fever,  and  frequent  stools.  There  is  constant 
desire  to  go  to  stool,  with  great  straining  and  tenesmus.  Every 
half  hour  or  so  there  may  be  a  passage  of  a  small  amount  of  blood 
and  mucus.  The  temperature  rises  and  may  reach  104° ;  the  pulse 
is  small  and  frequent,  the  tongue  furred,  and  there  is  great  thirst. 
In  very  severe  cases  the  condition  becomes  critical  in  48  hours  and 
death  may  ensue  on  the  third  or  fourth  day.  In  moderate  cases 
the  symptoms  gradually  abate  and  convalescence  is  established 
after  two  or  three  weeks.  The  Bacillus  dysenterm  is  found  in  the 
stools  and  agglutinates  with  the  blood  serum. 

Patholog'y. — When  death  occurs  on  the  fourth  to  the  seventh 
day  the  mucosa  of  the  large  intestine  is  swollen,  deep  red  in  color, 
and  presents  many  corrugations  and  folds.  There  are  also  hemor- 
rhagic spots.  There  is  no  ulceration,  but  a  general  superficial 
necrosis  of  the  mucosa.  These  conditions  extend  to  the  ileum  more 
frequently  than  the  corresponding  lesions  of  amebic  dysentery. 

Prophylaxis. — Since  the  germ  has  never  been  found  outside  the 
body,  and  since  the  mode  of  infection  is  not  known,  it  should  be 
assumed  that  it  is  communicated  by  carelessness  in  the  handling 
of  the  discharges,  and  the  hands  of  attendants  and  the  discharges 
themselves  should  be  disinfected  with  the  same  scrupulous  care 
as  in  Asiatic  cholera.  "Water  should  be  boiled,  the  milk  supply 
carefully  looked  after,  refrigerators  carefully  cleansed,  and  the 
food  in  general  carefully  gone  over.  Flies  should  especially  be 
guarded  against.  In  all  institutions — especially  those  having  the 
care  of  children — the  patient  should  be  isolated,  and  in  civil  prac- 
tice the  disease  should  be  made  notifiable  in  order  that  proper 
methods  of  disposing  of  the  stools  may  be  enforced. 

ASIATIC  CHOLERA. 

Definition. — A  specific  infectious  disease,  characterized  by  vomit- 
ing, purging  and  collapse.  The  infective  agent  is  the  Spirohacillus 
comma  of  Koch. 

Distribution. — Endemic  in  India — particularly  in  the  delta  of 
the  Ganges,  in  southern  China,  and  possibly  in  the  Philippines. 
At  intervals  of  several  years  it  becomes  epidemic  in  various  locali- 
ties— particularly  in  the  Orient,  and  has  on  several  occasions  in 
the  Nineteenth  Century  become  pandemic,  covering  almost  the  en- 
tire civilized  world. 

Etiology. — The  symptoms  of  the  disease  are  due  to  the  toxins  of 


72  PRACTICAL   SANITATION. 

the  bacillus  and  are  intimately  connected  with  its  proteid  content. 
They  are  so  unstable  that  it  is  yet  impossible  to  separate  them.  In 
acutely  fatal  cases  the  organism  does  not  invade  the  intestinal  wall, 
but  in  more  chronic  cases  this  occurs. 

Immunity. — There  is  no  certain  natural  immunity,  since  second 
attacks  within  a  short  time  of  the  original  but  too  late  to  be  con- 
sidered relapses  are  by  no  means  rare.  Artificial  immunity  of  some 
value  has  been  conferred  by  the  Haffkine  serum,  but  a  bacillary 
vaccine  prepared  after  the  method  of  Wright  has  proved  very  much 
more  successful. 

Incubation. — From  1  or  2  hours  to  6  days. 

Modes  of  Infection. — Always  by  the  mouth  in  infected  food  or 
water.  Fly-borne  infections,  as  well  as  infections  by  the  hands  of 
"carriers"  are  well-known.  Sudden  widespread  local  epidemics 
occurring  without  visible  connection  between  the  cases  are  due  to 
infected  water  supplies.  Air-borne  infection,  except  possibly  in 
dust,  is  not  known  and  must  be  rare  since  the  bacillus  is  sensitive 
to  drying  and  sunlight,  without  which  factors  dust  cannot  form. 

Pathology. — The  diagnosis  can  always  be  made  by  the  presence 
of  the  specific  organism.  The  body  shows  the  appearance  of  pro- 
found collapse.  There  may  be  post-mortem  elevation  of  tempera- 
ture. Eigor  mortis  sets  in  early  and  is  often  so  marked  as  to  cause 
movements  of  the  limbs.  The  blood  is  thick  and  dark,  owing  to 
the  amount  of  its  fluid  constituents  taken  out  by  the  vomiting  and 
purging.  The  peritoneum  is  sticky  and  congested  and  the  intes- 
tines shrunken.  The  small  intestine  may  contain  a  turbid  fluid 
rich  in  cholera  bacilli.  There  is  cloudy  swelling  of  the  liver  and 
kidneys. 

Symptoms. — Preliminary  Diarrhea. — There  is  commonly  a 
slight  looseness  of  the  bowels  with  colicky  pains,  perhaps  vomiting, 
headache  and  depression  of  spirits.  This  is  by  no  means  invariable, 
as  many  of  the  cases  seen  in  the  Philippine  epidemic  of  1902  by 
the  writer  showed  no  preliminary  symptoms  whatevtn-.  P\'ver  if 
present  is  slight. 

Collapse. — The  diarrhea  increases,  or  if  of  the  type  just  men- 
tioned sets  in  abruptly  with  the  greatest  intensity.  There  are 
griping  pains,  tenesmus,  cramps  in  the  lower  extremities.  The 
thirst  is  tormenting,  vomiting  severe,  the  tongue  covered  with 
white  dried  mucus.  The  features  are  shrunken,  the  eyeballs 
sunken,  nose  pinched,  cheeks  hollow,  and  the  body  literally  shriv- 


THE    TYPHOID   GROUP.  73 

elled.  The  skin  is  clammy  and  withered  and  the  skin  temperati:^t6^ 
low — even  as  much  as  ten  degrees  subnormal,  though  the  internal 
temperature  may  show  as  high  as  104°.  The  stools  are  at  first 
yellowish  with  bile  pigment,  but  soon  assume  the  distinctive  "rice 
water"  appearance,  the  floating  clumps  of  bacilli  looking  like  bits 
of  boiled  rice  or  sago  starch.  The  pulse  becomes  very  rapid  and 
feeble,  and  coma  may  come  on,  or  consciousness  may  be  retained 
till  the  very  end. 

Reaction  Stage. — ^When  the  patient  survives  the  stage  of  col- 
lapse, reaction  gi'adually  takes  place,  and  sometimes  with  almost 
as  great  rapidity  as  the  collapse  which  preceded  it.  All  the  symp- 
toms ameliorate  and  the  first  crisis  is  passed,  but  the  patient  has 
yet  the  dangers  of  urinary  suppression  and  a  chronic  form  of 
cholera  known  as  cholera  typhoid,  comparable  in  many  ways  to 
that  disease.  These  two  conditions  are  fatal  in  many  cases  which 
are  safely  past  the  stage  of  collapse. 

Cholera  Sicca  or  dry  cholera  is  the  name  given  to  an  atypical 
form  in  which  the  infection  is  so  intense  that  death  takes  place 
before  purging  begins,  sometimes  in  an  hour  or  less  from  the  first 
cramp. 

Differentiation. — Differentiate  from  Cholera  nostras,  a  precisely 
similar  affection  arising  in  summer  in  temperate  climates  from  a 
cause  as  yet  unknown.  Cholera  nostras  is  sometimes  fatal  in  as 
short  a  time  as  12  hours,  especially  in  feeble  people. 

As  before  stated,  the  diagnosis  of  Asiatic  cholera  is  most  cer- 
tainly to  be  made  by  the  bacteriologist,  though  one  who  has  had 
large  clinical  exi3erience  with  the  disease  can  almost  diagnose  it  in 
the  dark. 

Prophylaxis. — The  same  in  all  respects  as  for  typhoid  fever  with 
a  six  days'  quarantine  added  for  contacts  and  suspects.  The  pa- 
tient should  not  be  liberated  from  the  isolation  hospital  until  careful 
tests  show  the  stools  to  be  free  of  bacilli. 

Disinfection. — Exactly  as  for  typhoid  fever. 


CHAPTER  VII. 
THE  EXANTHEMATA. 

The  exanthemata  have  in  common  certain  skin  symptoms  or 
exanthems.  They  may  be  air-borne  or  communicated  by  fomites 
such  as  infected  clothing  or  rooms.  Insects  are  facultative  carriers, 
but  so  far  as  known  none  of  this  group  has  as  a  necessary  part  of 
its  etiology  an  extra  human  cycle,  like  that  of  malaria.  It  is  very 
possible,  however,  that  members  of  this  group  will  in  the  light  of 
fuller  knowledge  be  transferred  to  other  families,  as  has  already 
been  the  case  with  yellow  fever,  which,  a  dozen  years  ago  was  sup- 
posed to  be  communicable  in  the  same  manner  as  the  diseases  here 
classed  as  exanthematous. 

Such  discoveries  will  simplify  greatly  the  management  of  these 
diseases,  since  the  easiest  place  to  break  the  chain  of  infection  is 
between  the  human  and  the  extra-human  host.  These  disorders 
present  great  differences  in  the  tenacity  with  which  the  infection 
clings  to  convalescents  and  infected  articles,  which  variations  will 
be  noted  under  the  proper  heads. 

SMALLPOX. 

Synonym. — Variola. 

Definition. — An  acute  infectious  disease,  characterized  by  a  cu- 
taneous eruption  which  passes,  through  the  stages  of  papule,  vesicle, 
pustule  and  crust  (Osier). 

History. — This  disease  has  been  known  for  centuries,  particu- 
larly in  China.  Galen  described  a  pesfa  magna  which  is  now  identi- 
fied as  smallpox.  It  became  widespread  in  Europe  during  the  Sixth 
Century,  was  spread  by  the  Crusades,  introduced  into  the 
Western  Continent  during  the  Sixteenth  Century,  and  until  the 
discovery  of  vaccination  in  1796  by  Jenner  was  easily  the  first  of 
the  "Captains  of  the  Men  of  Death."  Since  that  time  in  com- 
munities where  vaccination  is  general  it  has  become  rare  and  far 
less  fatal. 

Etiology. — This  is  one  of  the  most  infectious  and  most  virulent  of 

74 


THE   EXANTHEMATA.  75 

transmissible  diseases  and  persons  unprotected  by  vaccination  are 
almost  universally  attacked  on  exposure.  Second  and  third  at- 
tacks are  sometimes  seen,  though  rarely.  Both  these  statements 
should  be  borne  in  mind;  complete  natural  immunity,  even  after 
repeated  exposure  is  occasionally  seen,  and  a  previous  attack  is  not 
a  guarantee  of  absolute  immunity. 

Age. — In  unvaccinated  communities  smallpox  is  a  disease  of  chil- 
dren and  is  more  fatal  than  later  in  life.  The  fetus  m  utero  may 
be  attacked,  but  only  if  the  mother  has  the  disease.  Children  born 
in  smallpox  hospitals  usually  escape  if  vaccinated  at  once  (Osier). 

Sex. — There  is  no  difference  of  predisposition  on  account  of  sex. 

Race. — The  dark-skinned  races  are  particularly  severely  attacked 
by  smallpox. 

Transmission. — The  mode  of  transmission  is  not  certainly  known. 
Direct  inoculation  was  employed  in  the  early  part  of  the  Eighteenth 
Century  in  Europe,  and  from  a  much  earlier  period  to  the  present 
time  it  has  been  in  use  as  a  protective  measure  in  the  Orient. 
There  is  a  good  deal  of  evidence  in  favor  of  aerial  transmission, 
but  it  is  rejected  by  many  authors,  notwithstanding  the  greater 
incidence  of  variola  in  the  neighborhood  of  isolation  hospitals  in 
cities. 

It  seems  that  flies  and  possibly  mosquitoes  may  act  as  carriers, 
at  least  in  summer.  The  commonest  cause  is  probably  contact  or 
proximity  to  a  case — a  proximity  close  enough  to  allow  the  throat 
and  nasal  or  skin  debris  to  be  inhaled  by  the  person  infected. 

Cause. — The  cause  is  not  known,  although  much  work  has  been 
done  on  the  subject.  Various  organisms  have  been  described, 
among  others  two  or  three  protozoon-like  bodies.  None  of  this 
work  is  well-confirmed,  and  it  is  not  generally  accepted. 

Epidemics. — The  prevalence  of  smallpox  is  subject  to  great  vari- 
ations. It  smoulders  in  certain  localities  for  a  long  time  and  then 
spreads  like  a  prairie  fire.  The  contagion  can  apparently  live  for 
a  long  time  in  clothing  and  the  like.  The  mortality  and  incidence 
of  the  disease  are  steadily  dropping  in  all  countries  where  vaccina- 
tion is  at  all  general. 

There  is  great  variation  in  the  severity  of  smallpox  epidemics, 
most  of  those  of  late  years  showing  so  low  a  mortality  that  the 
general  public  has  been  loth  to  accept  the  disease  as  genuine  small- 
pox, and  by  the  connivance  of  some  of  the  less  well-informed  of 
the  profession  it  has  frequently  been  called  "Cuban  itch."     It  is. 


76  PRACTICAL   SANITATION. 

however,  true  smallpox,  and  deaths  have  been  by  no  means  so  rare 
as  supposed  by  the  laity.  In  fact  several  recent  epidemics  have 
shown  rather  a  high  mortality. 

Pathology. — The  pustules  are  to  be  seen  on  the  tongue  and  inside 
the  cheeks,  on  the  pharynx,  and  even  down  the  esophagus  into  the 
stomach.  Peyer's  glands  may  be  swollen,  and  the  rectum  may 
show  the  pustules. 

The  eruption  in  the  larynx  may  be  associated  with  fibrinous 
exudate  or  edema,  or  the  cartilages  may  be  involved  by  ulceration. 
True  pocks  do  not  occur  in  this  locality. 

The  heart  sometimes  shows  inflammation  or  degeneration  of  its 
muscle.  The  spleen  is  enlarged  and  the  kidneys  may  show  nephritis 
during  convalescence. 

In  the  black  or  hemorrhagic  form  the  skin  and  mucous  mem- 
branes, the  serous  membranes,  the  tissues  of  many  organs,  the  con- 
nective tissue  and  the  nerve  sheaths  show  large  or  small  clots  formed 
from  the  blood  which  has  leaked  from  the  vessels. 

The  Pock. — The  specific  lesion  according  to  Councilman  and  his 
associates  is  "a  focal  degeneration  of  the  stratified  epithelium, 
vacuolar  in  character,  and  accompanied  by  serous  exudation  and 
the  formation  of  a  reticulum. ' '  The  most  important  feature  of  the 
pock  from  a  diagnostic  standpoint  is  its  regular  evolution  from 
papule  through  vesicle  and  pustule  to  crust.  Another  important 
point  is  the  presence  of  the  reticulum  or  network  within,  which  is 
readily  to  be  seen  on  picking  with  a  needle. 

Incubation. — 9  to  15  days;  most  often  12  days. 

Symptoms. 

Variola  Vera. — Stage  of  Invasion. — Convulsions  in  children  and 
a  chill  in  adults  commonly  are  the  first  symptoms  noted.  The  chill 
may  be  repeated  more  than  once  in  the  first  24  hours.  Intense 
frontal  headache  and  lumbar  pain  accompanied  by  vomiting  are 
very  constant  at  this  stage.  These  pains,  with  those  in  the  limbs, 
are  more  severe  than  in  any  other  of  the  eruptive  fevers,  and  when 
combined  with  the  other  symptoms  mentioned  should  at  once  lead 
to  the  suspicion  of  smallpox.  The  temperature  curve  is  very  sharp 
and  reaches  103°  or  104°  by  the  end  of  the  first  day,  or  even  sooner. 
The  pulse  is  full,  rapid,  not  often  dicrotic.  Delirium  may  be 
marked.  There  is  mental  distress,  with  bright  clear  eyes  and 
flushed  face,  and  in  severe  cases,  delirium.     In  place  of  the  usual 


THE   EXANTHEMATA.  77 

dry  skin,  there  may  be  profuse  sweating.  The  severity  of  the  initial 
symptoms  is  not  a  guide  to  the  ultimate  severity  of  the  case. 

Initial  Rashes. — There  are  two  forms  of  initial  rash,  one  re- 
sembling scarlet  fever  and  the  other  measles.  Either  form  may 
have  petechias  associated  and  may  occupy  a  limited  surface  or  may 
be  general.  As  a  rule  they  are  limited  to  the  lower  abdomen,  the 
inside  of  the  thighs,  the  sides  of  the  chest  or  the  armpits.  Some- 
times they  may  be  found  on  extensor  surfaces,  as  the  knees  or 
elbows.  These  rashes  are  found  in  from  10  to  16  per  cent  of  all 
cases,  and  the  scarlatinal  form  may  appear  as  early  as  the  second 
day. 

Eruption. — Discrete  Form. — Usually  on  the  fourth  day  spots  or 
ynacules  appear  on  the  forehead,  preceded  sometimes  by  a  red  flush, 
and  on  the  front  of  the  waists.  Within  24  hours  they  appear  on  the 
remainder  of  the  face,  on  the  extremities,  and  a  few  show  on  the 
trunk.  These  spots  are  from  1/20  to  1/12  inch  in  diameter,  and 
disappear  completely  on  pressure.  "With  the  appearance  of  the 
rash,  the  fever  drops,  the  pain  ceases  and  the  patient  feels  in  every 
way  better.  On  the  fifth  or  sixth  day  the  papules  are  changed  to 
vesicles  with  a  clear  apex.  These  vesicles  are  elevated,  circular, 
and  have  a  tiny  depression  or  umbilication  in  the  center. 

About  the  eighth  day  the  vesicles,  by  the  entrance  of  pus  organ- 
isms, are  transformed  into  pustules;  the  umbilication  disappears; 
the  pustule  becomes  globular  and  grayish  w^hite  instead  of  clear. 
The  skin  about  the  pustules  is  reddened  and  between  pustules  is 
swollen.  A  new  rise  of  temperature  occurs  and  the  secondary  fever 
begins.  The  general  symptoms  return.  The  face  and  eyelids  are 
swollen,  the  latter  often  closed.  The  temperature  in  the  form  under 
consideration  does  not  often  remain  high  more  than  24  to  36  hours, 
and  by  the  tenth  or  eleventh  day  the  fever  disappears  and  conva- 
lescence begins.  The  pustules  dry  in  the  order  of  appearance  and 
maturation,  first  on  the  face  and  afterwards  elsewhere. 

Distribution  op  Rash. — The  upper  part  of  the  back  is  often 
thickly  dotted  while  the  lower  part  has  scarcely  any.  The  abdomen, 
groins  and  legs  are  least  affected.  Vesicles  in  the  mouth,  pharynx 
and  larynx  cause  swelling  of  the  mucous  membrane  and  loss  of 
voice  or  hoarseness.  Pitting  is  not  usually  severe  in  this  form  of 
smallpox. 

Confluent  Form. — The  initial  symptoms  are  the  same  as  in  the 
discrete  form,  but  often  more  severe.     The  rash  also  appears  on 


78  PRACTICAL  SANITATION. 

the  fourth  day  (sometimes  on  the  third).  The  papules  are  isolated, 
though  in  the  severe  cases  very  close  together.  The  skin  is  swollen 
and  congested,  and  the  papules  are  thick  on  hands  and  feet,  less 
so  on  the  limbs  and  still  discrete  on  the  trunk.  The  eruption 
marches  as  before,  though  the  remission  which  comes  with  the  rash 
is  not  so  pronounced  as  in  the  discrete  form.  On  the  eighth  day, 
the  fever  again  comes  up,  maturation  takes  place,  and  by  the  tenth 
day  all  of  the  areas  which  are  to  become  confluent  will  do  so.  The 
pustules  coalesce  in  these  localities  to  form  great  superficial  abscesses 
which  may  involve  the  head  and  face  or  any  or  all  of  the  extremi- 
ties. 

The  fever  is  high — 105°  or  sometimes  higher,  the  pulse  110  or 
120,  and  there  is  often  delirium.  The  thirst  is  severe.  In  adults 
there  may  be  salivation,  in  children  severe  diarrhea.  The  cervical 
lymphatics  are  greatly  swollen.  The  eruption  inside  the  mouth 
may  be  severe,  and  the  voice  is  husky  or  lost. 

This  picture  is  one  of  the  most  terrible  seen  in  any  hospital,  and 
a  single  glance  by  a  layman  would  be  enough  to  counteract  the 
effect  of  a  library  of  anti-vaccination  literature. 

In  fatal  cases  by  the  tenth  or  eleventh  day  the  pulse  becomes 
more  rapid  and  feeble,  there  is  marked  delirium,  twitching  of  the 
tendons  supervenes,  sometimes  diarrhea  is  present,  and  the  patient 
succumbs.  Sometimes  hemorrhagic  features  come  up  at  the  time 
of  maturation  between  the  eighth  and  tenth  days. 

Desiccation. — The  pustules  are  broken,  and  the  pus  runs  out, 
or  they  dry  and  form  crusts.  This  proceeds  during  the  third  week, 
beginning  usually  on  the  eleventh  or  twelfth  day.  The  secondary 
fever  usually  subsides  as  this  goes  on,  but  may  persist  into  the 
fourth  week.  In  confluent  smallpox  the  crusts  are  very  adherent, 
and  the  process  of  healing  may  take  several  weeks.  On  the  face 
the  crusts  are  shed  singly,  but  on  the  hands  and  feet  the  epidermis 
may  be  shed  in  large  sheets  or  entirely. 

Hemorrhagic  Forms  (Purpura  Variolosa). — In  this  variety  of 
smallpox  the  disease  starts  in  the  usual  manner,  but  the  constitu- 
tional symptoms  are  more  intense.  On  the  evening  of  the  second 
day  or  the  morning  of  the  third  there  is  a  diffuse  congested  rash, 
particularly  in  the  groins  with  fine  points  of  hemorrhage.  The 
rash  extends,  becomes  more  distinctly  hemorrhagic,  and  the  spots 
increase  in  size.  Blood  spots  appear  on  the  conjunctivce,  and  as 
early  as  the  third  day  there  may  be  hemorrhages  from  mucous  mem- 


THE   EXANTHEMATA.  79 

branes.  Death  may  take  place  before  the  papules  appear.  The 
whole  body  may  be  purplish  or  plum-colored.  The  face  is  swollen 
and  the  effusions  of  blood  into  the  eyes  give  a  peculiarly  ghastly 
appearance.  The  mind  remains  clear.  In  Osier's  13  cases,  death 
took  place  no  earlier  than  the  third  day  and  no  later  than  the  sixth. 
There  may  be  no  mucous  hemorrhage,  or  it  may  occur  from  the 
lungs,  stomach,  kidneys  or  uterus.  The  pulse  is  often  rapid,  hard, 
and  small.  Eespiration  is  very  rapid  and  out  of  proportion  to  the 
fever. 

Variola  Pustulosa  Hemorrhagica. — This  form,  that  of  hemor- 
rhage into  the  pocks,  has  already  been  mentioned.  The  bleeding 
first  occurs  into  the  areolae  around  the  pocks  and  the  pustules  fill 
them  with  blood.  Bleeding  from  mucous  membranes  is  common 
and  most  cases  prove  fatal  from  the  seventh  to  the  ninth  day,  but 
recovery  occurs  rarely.  If  patients  with  discrete  smallpox  are  al- 
lowed to  get  up  too  soon,  hemorrhage  may  occur  in  the  pocks 
on  the  legs,  a  condition  which  is  not  to  be  confused  with  the 
above. 

Abortive  Types. — Most  late  epidemics  have  been  characterized  by 
the  great  percentage  of  mild  cases.  Even  in  unvaccinated  children 
the  disease  has  been  almost  trifling  as  a  usual  thing,  mth  only  a 
few  pustules,  and  a  course  of  a  few  days  only.  A  type  known  as 
wart  or  horn-pox  in  which  the  vesicles  do  not  suppurate  but  dry 
up  instead  at  the  fifth  or  sixth  day  has  been  somewhat  common. 
Variola  sine  eruptione  in  which  the  preliminary  symptoms  of  back- 
ache, headache,  vomiting  and  pains  in  the  limbs  are  present,  but  the 
eruption  is  either  absent  or  so  scanty  as  to  be  overlooked,  has  been 
observed,  particularly  among  physicians  and  attendants  in  smallpox 
hospitals. 

Varioloid. — ^Varioloid  is  smallpox  modified  by  vaccination.  It 
may  have  an  abrupt  onset  with  the  usual  symptoms  of  smallpox 
and  a  temperature  reaching  103°,  but  ordinarily  the  initial  symp- 
toms are  milder  than  in  unmodified  variola.  The  papules  appear 
on  the  evening  of  the  third  day  or  on  the  fourth,  are  few  in  num- 
ber and  usually  confined  to  face  and  hands.  The  fever  drops  at 
once  and  the  patient  becomes  comfortable.  The  vesiculation  and 
maturation  take  place  rapidly  without  secondary  fever.  There  is 
usually  little  scarring.  For  persons  attacked  within  5  or  6  years 
of  a  successful  vaccination  the  rule  is  to  have  the  disease  in  a  mild 
form,  but  it  may  be  severe  or  even  fatal. 


80  PRACTICAL   SANITATION. 

Complications. — The  complications  of  smallpox  are  few,  consid- 
ering the  severity  of  the  disease. 

Laryngitis. — This  may  produce  fatal  edema  of  the  glottis,  may 
cause  necrosis  of  the  cartilages,  or  may  favor  the  aspiration  of 
irritating  particles  into  the  bronchi  or  air-cells,  causing  bronchitis 
or  broncho-pneumonia. 

BroncJio-pnewnonia  is  almost  always  present  in  fatal  cases. 

Lol)ar  'pneumonia  is  uncommon. 

Pleurisy  is  sometimes  seen,  and  is  common  in  some  epidemics. 

Heart  complications  are  rare.  At  the  height  of  the  disease  an 
apical  systolic  murmur  may  be  heard,  but  endocarditis,  either  sim- 
ple or  malignant,  and  pericarditis  are  rarely  seen.  Inflammation 
of  the  heart  muscle  is  more  frequent  and  may  be  associated  with 
endarteritis  of  the  coronary  arteries. 

Parotitis  is  rare.  There  may  be  an  exudate  like  that  of  diph- 
theria in  the  throat  in  severe  cases. 

Vomiting  while  constant  in  the  early  stages  is  not  often  per- 
sistent. 

Diarrhea  is  common  and  very  constantly  present  in  children. 

Albuminuria  is  frequent;  true  nephritis  is  rare. 

Nervous  symptoms  are  very  important.  The  convulsions  of  chil- 
dren are  quite  regularly  present,  and  in  adults  the  early  delirium 
may  become  constant  and  violent,  finally  subsiding  into  fatal  coma. 
Insanity  and  epilepsy  are  sometimes  sequelae.  A  toxic  newitis  like 
that  of  diphtheria  may  follow  the  disease. 

Boils,  acne,  ecthyma  and  local  gangrene  of  the  skin  may  occur 
during  convalescence  as  a  result  of  persisting  micro-organisms  be- 
longing to  the  secondary  infection. 

Recurrent  smallpox,  a  secondary  eruption  occurring  after  the 
desquamation  is  sometimes  seen. 

The  eyes  are  frequently  attacked  by  iritis,  conjunctivitis,  and 
corneal  ulcers. 

Middle  ear  inflammations  are  occasionally  seen,  the  infection 
passing  in  from  the  throat  through  the  Eustachian  tube. 

Diagnosis. — During  an  epidemic  the  initial  chill,  backache,  head- 
aclie  and  vomiting  will  at  once  put  the  physician  on  his  guard,  but 
if  dengue  or  influenza  is  present  in  the  community,  he  will  be  in 
doubt  until  the  appearance  of  the  papules.  The  initial  rash  may 
resemble  scarlet  fever,  measles  or  dengue,  and  be  still  more  a  cause 
of  confusion.     The  scarlatiniform  rash  has  rarely  the  extent  and 


THE   EXANTHEMATA. 


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'82  PRACTICAL   SANITATION. 

never  the  persistence  of  the  rash  in  true  scarlet  fever.  Measles 
may  be  mistaken  for  the  preliminary  rash  of  smallpox,  but  Koplik  's 
sign  will  at  once  differentiate. 

Hemorrhagic  Smallpox,  Hemorrhagic  Scarlet  Fever  and  Hemor- 
rhagic Measles  may  be  impossible  of  differentiation,  but  to  the  sani- 
tarian the  point  is  rather  academic  than  otherwise,  because  the 
same  measures  are  required  for  prophylaxis,  and  the  cases  which 
cannot  be  recognized  are  the  ones  which  die  before  the  disease  is 
properly  developed. 

A  peculiar  odor  is  by  many  said  to  be  characteristic  of  smallpox. 

Chichenpox  shows  points  of  difficulty  in  connection  with  the  mild 
epidemics  of  smallpox  seen  of  late  years.  The  eruption  of  chicken- 
pox  is  more  superficial,  the  feel  is  less  shotty  or  not  at  all  so;  the 
areola  of  injection  is  less  marked,  and  there  are  usually  successive 
crops  in  various  stages. 

Pustular  Syphilides  if  accompanied  by  fever  are  sometimes  mis- 
taken for  smallpox,  but  the  history  of  the  case  and  distribution  of 
the  eruption  should  leave  no  doubt. 

Pustular  Glanders  in  a  Montreal  epidemic  (Osier)  was  confused 
with  smallpox.  The  presence  of  the  glanders  bacillus  (B.  mallei) 
should  at  once  settle  the  diagnosis.  An  incidental  point  would  be 
the  occurrence  of  an  epizootic  of  glanders  among  horses. 

Impetigo  Contagiosa  and  smallpox  have  sometimes  been  confused. 

Prognosis. — In  unvaccinated  whites  the  mortality  is  25  to  35 
per  cent;  in  negroes,  42  per  cent,  and  in  the  red  and  Malay  races, 
for  which  figures  are  not  now  ascertainable,  it  is  very  high. 

The  prognosis  for  the  individual  is  based  on  the  thickness  of  the 
eruption  on  the  face  and  hands,  and  is  bad  directly  proportional 
to  its  severity.  The  eruption  on  the  remainder  of  the  body  is 
disregarded  for  this  purpose. 

Individual  Prophylaxis. — Vaccination  and  revaccination. 

Community  Prophylaxis. — Vaccination  of  all  children  within  the 
first  year  of  life,  whether  smallpox  is  prevalent  or  not,  and  revacci- 
nation at  intervals  of  a  few  years  through  life,  are  the  surest  means 
of  protecting  the  community. 

Isolation  of  the  sick  in  proper  hospitals  is  of  great  importance. 

Quarantine. — For  the  Sick. — Until  desquamation  is  complete  and 
the  skin  thoroughly  healed,  not  less  than  21  days. 

For  Contacts. — Quarantine  for  14  days.     Vaccination  and  sur- 


THE   EXANTHEMATA.  83 

veillance  may  be  substituted  in  selected  cases,  if  permitted  by  the 
rules  of  the  State  Board  of  Health. 

Disinfection. — The  patient  must  have  a  soap  and  water  bath, 
paying  particular  attention  to  the  hair,  followed  by  a  1 :2000  bi- 
chloride bath  on  two  successive  days  after  desquamation  is  com- 
plete. One  room  is  disinfected  and  within  it  is  placed  a  complete 
change  of  clothing  for  the  patient.  The  patient  walks  nude  from 
the  bath  to  the  disinfected  room,  puts  on  the  clothing,  and  is  re- 
leased from  quarantine.  After  arranging  the  rooms  for  disinfec- 
tion, the  nurse  takes  an  antiseptic  bath  following  a  thorough  soap 
and  water  scrub — paying  attention  to  the  hair,  starts  the  formalde- 
hyd  or  sulphur  fumigation  (formaldehyd  being  preferred),  changes 
into  clean  or  disinfected  clothing  in  the  disinfected  room,  and  the 
house  is  exposed  to  the  action  of  the  disinfectant  for  at  least  12 
hours. 

VACCINIA. 

Synonyms. — Vaccination;  Cowpox. 

Definition. — An  infectious,  eruptive  disease  of  cattle,  which,  when 
communicated  to  the  human  species,  protects  partially  or  more 
generally  completely  for  several  years  against  smallpox.  The  ac- 
quirement of  this  immunity  is  signalized  by  the  appearance  of  a 
local  reaction  or  vaccine  pock,  and  by  more  or  less  severe  general 
symptoms. 

Etiology. — Experiments  in  Great  Britain  and  in  India  seem  to 
prove  that  the  inoculation  of  true  smallpox  virus  into  the  cow 
carried  through  one  or  two  generations  will  produce  vaccinia  or 
cowpox.  At  one  time  this  method  was  used  commercially  on  quite 
a  scale  for  obtaining  commercial  vaccine.  It  is  mentioned  here 
as  in  isolated  places  remote  from  facilities  for  obtaining  vaccine  it 
might  enable  the  sanitarian  to  produce  his  own  supply.  Such  a 
supply,  produced  hurriedly  in  the  presence  of  an  advancing  epi- 
demic, with  poor  facilities  for  aseptic  care  of  the  animals  and  for 
purifying  the  product,  would  be  much  inferior  to  the  best  com- 
mercial vaccine,  but  the  experiment  is  worth  considering  under 
appropriate  circumstances. 

On  the  other  hand,  certain  other  experiments  of  the  same  nature 
carried  on  in  France  seem  to  contradict  these  statements,  since 
true  smallpox  was  apparently  transmitted  when  the  virus  was  rein- 


84  PRACTICAL   SANITATION. 

oculated  into  children.  Nevertheless,  the  weight  of  evidence  is  in 
favor  of  the  first  view. 

A  protozoon-like  body  having  characteristics  like  those  supposed 
to  have  been  found  in  smallpox,  has  also  been  found  in  vaccinia, 
according  to  some  observers,  but  as  in  the  case  of  smallpox,  these 
observations  have  failed  to  find  acceptance  with  the  great  body 
of  pathologists. 

Normal  Vaccination. — Period  op  Incubation. — This  is  marked 
by  nothing  more  than  a  slight  local  irritation  due  to  the  abrasions 
made  in  the  operation  of  vaccination. 

Eruption. — On  the  third  day,  sometimes  not  until  the  fourth,  a 
small  papule  appears,  surrounded  by  a  reddish  areola.  This  in- 
creases and  on  the  fifth  or  sixth  day  is  transformed  into  a  true 
vesicle,  with  raised  margins  and  depressed  center.  This  vesicle 
reaches  the  maximum  on  the  eighth  day,  when  it  is  round  and  filled 
with  clear  fluid,  with  hard  and  prominent  margin  and  even  more 
distinct  umbilication.  On  the  tenth  day  the  contents  are  purulent 
and  the  surrounding  red  zone  is  extensive.  On  the  eleventh  or 
twelfth  day  the  congestion  diminishes,  the  contents  of  the  pock 
grow  more  opaque  and  begin  to  dry.  At  the  end  of  the  second 
week  in  typical  cases  nothing  is  left  but  a  brownish  scab,  which  in 
another  week  or  ten  days  drops  off,  leaving  a  circular  pitted 
scar. 

Constitutional  Symptoms. — Usually  on  the  third  or  fourth  day 
there  is  a  rise  of  temperature  which  may  persist  for  4  or  5  days 
longer ;  there  is  leucocytosis,  quite  marked ;  in  children  restlessness 
and  irritability,  particularly  at  night;  the  tributary  lymphatic 
glands  near  the  site  of  the  inoculation  are  often  enlarged  and 
painful. 

Duration  of  Immunity. — This  may  be  permanent  but  ordinarily 
is  not  longer  than  10  or  12  years,  and  in  the  presence  of  smallpox 
revaccination  should  be  done  regardless  of  the  date  of  previous 
inoculations.  In  the  United  States  Army  and  Navy,  revaccination 
is  required  at  frequent  intervals,  with  the  result  that  smallpox  is 
extremely  rare,  although  the  duties  of  soldiers  and  marines  take 
them  into  many  places  where  the  contagion  of  smallpox  is  likely 
to  be  found. 

Natural  insusceptibility  to  vaccination  is  sometimes  seen,  where 
the  freshest  virus  most  carefully  applied  repeatedly  fails.  Such 
cases  are  probably  also  immune  to  smallpox,  but  should  be  vacci- 


THE   EXANTHEMATA.  85 

nated  at  each  recurrent  epidemic  as  there  is  no  means  of  knowing 
when  this  natural  immunity  may  lapse. 

Local  Variations. — The  vesicle  occasionally  develops  rapidly 
with  much  itching,  is  not  characteristically  flattened,  and  progresses 
to  the  crust  by  the  seventh  or  eighth  day.  Sometimes  the  contrary 
is  true  and  the  process  goes  on  with  abnormal  slowness.  In  the 
second  case  revaccination  with  a  proved  fresh  lymph  is  advisable. 
Also  the  contents  of  the  vesicle  may  be  watery  or  bloody,  or  very 
rarely  a  second  pock  may  form  at  the  site  of  the  first,  a  process 
comparable  to  recurrent  smallpox. 

Generalized  Vaccinia. — Not  uncommonly  secondary  vesicles 
may  form  near  the  primary,  and  more  rarely  there  is  a  general 
pustular  rash,  covering  considerable  portions  of  the  body,  but  be- 
ginning usually  on  the  wrists  or  back  and  sometimes  appearing  in 
successive  crops  for  several  weeks.  The  eruption  is  most  prominent 
on  the  vaccinated  limb  as  a  general  thing  and  begins  on  the  eighth 
or  tenth  day.  In  children  vaccinia  of  this  type  has  extremely 
rarely  caused  death. 

Complications. — The  most  conmion  complications  are  the  result 
of  secondary  inoculation  of  pus  cocci,  tetanus  bacilli  or  similar 
ol-ganisms  as  the  result  of  injury  or  uncleanliness. 

A  depressed  state  of  the  general  health  has  been  thought  to  favor 
infections  of  this  nature.  •  There  may  be  sloughing,  deep  cellulitis, 
suppuration  of  axillary  or  inguinal  lymphatic  glands,  or  purpura. 

The  complications  are  arranged  chronologically  by  Acland,  thus : 

First  3  days:  erythema;  urticaria;  vesicular  and  bullous  erup- 
tions; invaccinated  erysipelas. 

Fourth  day  to  maturity  of  pock:  urticaria;  lichen  urticatus; 
erythema  multiforme;  accidental  erysipelas. 

About  end  of  first  week :  generalized  vaccinia ;  impetigo ;  vaccinal 
ulceration;  glandular  abscess;  septic  infections;  gangrene. 

After  involution  of  pock:  invaccinated  diseases,  as  for  example, 
syphilis. 

Tetanus. — Tetanus  being  practically  always  an  accidental  in- 
fection, the  time  of  its  appearance  is  not  to  be  predicted.  Ninety- 
five  cases  of  vaccination  tetanus  are  recorded  by  McFarland,  nearly 
all  occurring  in  the  United  States.  Sixty-three  of  these  cases  oc- 
curred in  1901,  most  of  which  could  be  traced  to  a  single  source, 
from  which  the  tetanus  organism  was  recovered.  Since  the  Bacillus 
tetani  is  normally  present  in  the  intestines  of  cattle,  the  chance  of 


86  PRACTICAL   SANITATION. 

contaminating  the  l.ymph  is  always  present.  It  is  not  fair  to  charge 
the  operation  of  vaccination  with  all  of  this  mortality,  however,  as 
similar  slight  wounds  are  not  infrequently  contaminated  by  acci- 
dent with  subsequent  development  of  tetanus. 

Tuberculosis. — The  British  Royal  Commission  on  Vaccination 
was  unable  to  find  a  single  instance  of  undoubted  invaccination  of 
tuberculosis,  so  that  if  it  occurs  it  must  be  excessively  rare. 

Actinomycosis. — No  reports  of  ray-fungus  ("lump-jaw")  infec- 
tion are  available,  but  the  organism  has  been  found  in  24  out  of  95 
cultures  from  the  product  of  5  different  producers. 

Choice  of  Lymph. — All  of  the  commercial  lymphs  now  sold  in 
the  United  States,  whether  produced  at  home  or  abroad,  are  pro- 
duced in  establishments  licensed  by  the  National  Government,  and 
inspected  at  frequent  irregular  intervals  by  officers  of  the  Public 
Health  and  Marine  Hospital  Service.  Each  lot  of  lymph  is  re- 
quired to  be  bacteriologically  tested,  and  is  obtained  and  treated 
as  follows : 

Perfectly  healthy  calves  are  selected.  The  posterior  half  of  the 
belly  is  shaved,  cleansed,  scarified  in  parallel  lines,  and  inoculated 
with  mature  virus.  The  vesicles  form  along  the  lines  of  scarifica- 
tion; when  mature  (about  the  eighth  or  ninth  day)  their  contents 
are  removed  under  the  strictest  aseptic  precautions,  mixed  with 
glycerin  and  allowed  to  "ripen"  for  4  to  6  weeks.  It  is  frequently 
tested  for  potency  and  freedom  from  contamination,  and  if  it 
meets  the  government  requirements  is  prepared  for  market — either 
dried  on  ivory  points  or  put  up  in  small  glass  tubes.  The  capillary 
tubes  containing  only  sufficient  for  one  inoculation  or  the  ivory 
points  are  preferable  to  the  tubes  containing  residual  pulp  left 
from  the  glycerin  extract.  As  an  additional  safeguard,  some  if 
not  all  of  the  large  commercial  houses  kill  the  animals  and  subject 
them  to  autopsy  before  marketing  the  lymph.  Special  care  and 
tests  are  used  to  insure  freedom  from  tetanus  bacilli  in  the  finished 
product.  Each  package  of  lymph  is  stamped  with  a  date  of 
expiration  beyond  which  the  percentage  of  takes  is  likely  to  be 
unsatisfactory,  and  is  traceable  through  its  entire  history  by  the 
manufacturer's  guarantee  number  and  serial  package  number. 

Economy  op  Production. — A  report  of  the  British  Local  Gov- 
ernment Board  states  that  whereas  formerly  it  was  only  possible 
to  obtain  material  for  from  200  to  300  vaccinations  from  a  calf, 
since  the  introduction  of  glycerinization  it  is  possible  to  obtain 


THE   EXANTHEMATA.  87 

from  -1,000  to  5,000  units  from  one  animal.  While  this  would  seem 
to  make  the  retail  price  of  vaccine  lymph  too  high,  it  must  be  re- 
membered that  for  a  plant  to  produce  a  good  article  it  must  be 
expensively  equipped,  employ  a  considerable  number  of  experts 
and  stand  large  "overhead"  expenses.  The  return  privilege  for 
unused  out-of-date  vaccine  is  also  an  expense  met  by  the  consumer, 
and  the  commercial  profits  of  the  drug-store  must  be  paid. 

Humanized  Lymph. — The  use  of  human  lymph  is  almost  un- 
known in  the  United  States  of  recent  years,  but  in  remote  districts 
its  use  may  be  necessary  in  order  to  eke  out  a  scanty  supply  of 
animal  lymph.  It  is  not  to  be  recommended  except  in  the  presence 
of  a  real  emergency,  on  account  of  the  ease  with  which  other  dis- 
eases, particularly  syphilis,  may  be  communicated.  Human  vaccine 
Ij^mph  should  be  taken  from  a  perfectly  healthy  child,  from  un- 
broken and  perfectly  formed  pocks,  on  the  eighth  day.  The  surface 
should  be  carefully  pricked  or  scratched,  allowing  the  lymph  to 
exude,  but  using  scrupulous  care  not  to  draw  blood.  This  lymph 
is  collected  on  ivory  points  or  better  in  capillary  tubes  and  is  used 
in  the  same  manner  as  the  bovine  lymph. 

Time  and  Method  of  Vaccination. — In  the  presence  of  smallpox 
epidemics,  infants  of  any  age  may  be  vaccinated.  If  there  is  no 
pressing  need,  vaccination  is  best  delayed  to  the- age  of  4  to  6 
months  if  children  are  healthy,  and  in  sickly  babies  it  may  be  de- 
layed to  the  age  of  1  year. 

A  baby  is  best  vaccinated  on  the  outer  side  of  the  calf  of  the 
left  leg  if  the  mother  is  right-handed,  or  in  the  same  place  on  the 
right  leg  if  left-handed,  for  the  reason  that  in  handling  the  child 
or  holding  it  the  inaculation  will  then  be  most  naturally  held  away 
from  contact  with  the  mother's  body  (M'athewson).  The  leg  is  the 
preferable  site  rather  than  the  arm,  for  the  reason  that  the  abundant 
lymphatics  of  the  groin  control  better  the  inflammatory  reaction 
following  than  do  the  less  developed  ones  of  the  axillary  region. 

Women  in  society  usually  prefer  the  calf  of  the  leg  also  for  cos- 
metic reasons.  In  right-handed  men  the  left  arm  is  most  often 
chosen,  a  spot  being  selected  on  the  outer  side  5  or  6  inches  below 
the  top  of  the  shoulder. 

The  desired  spot  should  be  well  scrubbed  with  sterile  soap  and 
boiled  water,  using  a  soft  sterilized  brush  or  piece  of  sterile  gauze. 
After  scrubbing,  the  skin  should  be  washed  again  with  alcohol  and 
allowed  to  dry  thoroughly.     It  must  be  remembered  that  any  anti- 


88  PRACTICAL  SANITATION. 

septic  in  the  skin  will  defeat  the  object  of  the  vaccination.  For 
this  reason  alcohol,  which  is  a  volatile  antiseptic,  is  chosen  and 
allowed  to  evaporate  after  having  done  its  work. 

A  fine  cambric  needle  is  inserted  by  the  eye-end  into  a  cork  and 
sterilized  by  heating  to  redness  in  the  flame  of  an  alcohol  lamp 
and  after  cooling,  the  skin  is  cross-hatched  over  an  area  half  the 
size  of  a  dime,  aiming  to  break  the  lymphatic  channels  but  without 
drawing  blood.  Ivory  points  may  be  used  in  the  same  way,  or  little 
metal  scarifiers  supplied  with  the  packages  of  lymph,  but  the  needle 
is  to  be  preferred. 

Army  orders  require  3  areas  to  be  scarified  and  inoculated  in  a 
triangle  about  2  inches  on  a  side.  This  is  to  be  recommended  in 
the  case  of  smallpox  contacts. 

After  scarification,  the  lymph  is  applied  and  allowed  to  dry  be- 
fore any  dressing  is  put  on.  This  may  be  a  celluloid  shield  which 
holds  the  clothing  from  contact  with  the  vaccination,  but  does  not 
itself  touch  it  anywhere,  or  it  may  be  a  simple  pad  of  sterile  gauze 
held  in  place  by  zinc  oxide  plaster. 

After  Care. — If  a  gauze  dressing  is  applied,  unless  soiled  it  should 
not  be  touched  till  the  third  or  fourth  day,  when  the  ''take"  occurs. 
This  should  be  smeared  over  with  zinc  oxide  ointment  and  a  new 
sterile  dressing  put  on.  If  infection  seems  to  be  occurring,  a  wet 
bichloride  dressing,  1  -.2000,  should  be  put  on.  If  a  shield  is  used 
it  is  often  possible  to  let  a  case  get  completely  well  before  touching 
the  dressing,  otherwise  it  may  be  treated  as  above. 

Satisfactory  takes  are  much  easier  to  recognize  than  to  describe. 
If  the  appearance  of  the  "take"  is  not  satisfactory,  revaccination 
should  be  done. 

Perfect  scars  according  to  Welch  and  Schamberg  are  "round  or 
oval,  below  the  level  of  the  surrounding  skin,  with  well-defined 
margins,  pitted  or  reticulated,  and  looking  as  if  stamped  into  the 
skin.  Large  flat  scars  are  not  signs  of  a  good  take,  but  of  infection 
of  the  vaccination  wound ;  large  pits  about  the  edges  of  a  scar  are 
a  good  sign  of  a  take;  the  smaller  pits  scattered  over  the  surface 
of  a  large  flat  scar  are  generally  the  dilated  mouths  of  hair-follicles 
and  sebaceous  glands. ' ' 

Vaccination  hy  Mouth. — A  few  physicians  unfamiliar  with  the 
real  processes  involved  in  vaccination  and  pushing  a  therapeutic 
dogma  to  extremes,  have  given  triturations  of  vaccine  matter  with 
sugar  of  milk  by  the  mouth,  with  the  idea  of  thereby  securing  the 


THE   EXANTHEMATA.  89 

same  result  as  by  the  classical  method  of  vaccination.  The  health 
officer  will  look  with  suspicion  on  certificates  of  vaccination  issued 
by  any  physician  known  to  entertain  such  views,  and  will  investigate 
the  presence  of  a  scar  or  otherwise  ascertain  if  the  so-called  vacci- 
nation has  been  of  this  description.  The  administration  of  vaccine 
matter  by  the  mouth  has  been  held  by  the  courts  not  to  comply  with 
the  legal  requirements  where  vaccination  is  made  compulsory  for 
any  purpose,  and  it  can  on  no  account  be  accepted  as  a  vaccination 
from  the  standpoint  of  the  sanitarian.  Those  who  give  certificates 
of  vaccination  based  on  it  should  be  prosecuted. 

Objections. — The  objections  to  vaccination,  with  their  answers 
are  well  summed  up  by  Mathewson: 

It  is  Dangerous. — The  dangers  of  vaccination  exist  chiefly  in  the 
minds  of  the  opponents  of  vaccination.  The  chief  source  of  danger 
remaining  is  an  accidental  infection  of  the  wound  caused  by  the 
vaccination.  In  this  a  vaccination  wound  but  shares  in  the  danger 
of  any  wound  to  infection.  This  in  vaccination  amounts  to  1  case 
of  fatal  infection  in  65,000  cases.  Voight- reports  2,275,000  cases 
in  Germany  with  a  total  of  35  deaths.  Recently  he  reports  100,000 
cases  with  but  one  death.  Hodgetts  reports  40,000  vaccinations 
done  in  the  Province  of  Ontario,  Canada,  without  a  death.  These 
statistics  show  that  vaccination  is  less  dangerous  than  the  extraction 
of  a  tooth  or  the  taking  of  an  anesthetic. 

It  is  Useless. — This  statement  is  based  on  the  undenied  fact  that 
vaccinated  persons  sometimes  have  smallpox.  The  protection  of 
vaccination  becomes  exhausted,  and  the  disease  is  contracted ;  or  the 
person  is  exposed  to  smallpox,  is  vaccinated,  and  has  the  disease  in 
spite  of  the  vaccination.  Prussia  is  the  most  thoroughly  vaccinated 
nation  in  Europe,  and  from  1874  to  1901  inclusive,  there  died  from 
smallpox  1.3  persons  per  100,000  as  against  42.1  persons  per  100,000 
under  voluntary  vaccination,  and  approximately  1  in  7  in  the  days 
before  vaccination.  No  case  of  smallpox  has  ever  been  known  to 
occur  in  a  person  recently  successfully  vaccinated.  Attendants  in 
smallpox  hospitals  are  vaccinated  and  revaecinated  frequently  and 
smallpox  is  unknown  among  those  so  protected. 

At  the  Highgate  Hospital  near  London,  where  hundreds  of  small- 
pox patients  are  treated,  but  one  attendant  in  the  past  60  years 
has  taken  smallpox,  and  that  attendant  was  a  gardener  who  was 
not  vaccinated  because  he  did  not  come  in  contact  with  the  patients. 

The  mortality  among  the  vaccinated  is  as  1  to  7  among  the  un- 


Deaths. 

Per  Cent, 

461 

5.0 

822 

3.5.1 

90  PRACTICAL   SANITATION. 

vaccinated,  as  shown  by  the  following  table  from  the  reports  of 
the  British  Royal  Vaccination  Commission: 

Cases. 

Vaccinated    8,744 

Unvaccinated    2,321 

It  is  an  Invasion  of  the  Eights  of  the  Individual. — There  is  no 
answer  to  this  argument  if  we  grant  that  the  individual  has  a  right 
to  do  as  he  pleases.  This  may  be  granted  if  the  individual  lives 
alone  and  comes  in  contact  with  no  other  human  being.  Life 
in  conununities  invades  and  restricts  the  right  of  the  savage,  and 
community  life  is  impossible  on  any  other  terms.  The  police  power 
of  the  community  rests  on  either  the  public  nuisance  or  the  public 
welfare  ideas  in  common  and  constitutional  law,  i.  e.,  an  individual 
may  not  maintain  a  public  nuisance  and  a  group  of  individuals 
may  act  together  for  the  public  welfare.  Compulsory  vaccination 
laws,  where  they  exist  have  been  upheld  unanimously  by  all  courts 
of  appeal  before  which  they  have  been  tested,  and  the  right  of  the 
community  to  enforce  vaccination  for  the  public  welfare  has 
been  established.  The  individual  who  in  exercising  his  right  to 
do  as  he  pleases  contracts  smallpox  is  conveyed  to  a  pesthouse  as 
a  public  nuisance,  and  his  family  is  quarantined  for  the  public 
good. 

Doctors  Favor  It  for  the  Fee  that  They  Get  for  Yaccination. — 
This  trifling  argument  may  be  answered  thus:  Vaccination  is 
usually  performed  free  of  charge  by  sanitary  officers,  and  the  cost 
is  borne  by  the  city  or  State  wherever  vaccination  is  compulsory. 
Where  vaccination  is  voluntary  and  paid  for  by  the  individual,  a 
physician  will  receive  more  for  the  treatment  of  one  moderately 
severe  ease  of  smallpox  than  for  100  vaccinations. 

All  Smallpox  Statistics  are  False. — "Whether  or  not  statistics  are 
kept,  smallpox  does  exist  and  kills  or  scars  its  victims  and  the  fact 
of  its  existence  and  the  danger  remain,  even  if  the  disease  is  dis- 
guised under  the  name  of  measles,  chickenpox,  Philippine  or  Cuban 
itch,  or  any  other  designation. 

Compulsory  Vaccination. — Laws  compelling  vaccination  are  in 
force  in  many  countries  and  in  many  States  and  cities  in  this  coun- 
try. The  highest  standard  in  the  drafting  and  enforcement  of 
these  laws  is  found  in  the  German  Empire,  and  particularly  in 
Prussia,  where  every  child  must  be  vaccinated  during  the  first  year 


THE   EXANTHEMxiTA.  91 

of  life  and  again  during  the  twelfth  year.  Later  revaccination  is 
not  required. 

In  the  United  States  and  its  dependencies  the  most  brilliant  re- 
sults are  to  be  found  in  the  Philippine  Archipelago,  where  com- 
pulsory vaccination  has  reduced  the  mortality  from  smallpox  almost 
to  the  vanishing,  point  as  against  an  average  death-rate  under 
Spanish  rule  of  6,000  known  deaths  per  annum.  Many  States  which 
do  not  in  terms  require  vaccination,  make  it  a  requisite  for  admis- 
sion to  the  schools,  and  make  attendance  at  school  compulsory, 
which  arrives  at  the  same  point  by  a  somewhat  devious  route. 

There  is  not  the  slightest  doubt  of  the  advisability  of  compelling 
vaccination  of  every  person  from  a  sanitary  point  of  view.  If  a 
strong  public  sentiment  exists  against  it,  the  alternative  plan  of 
doing  away  entirely  with  quarantine  for  smallpox  would  afford  a 
demonstration  which  would  convert  the  most  confirmed  doubter. 
Such  a  plan  has  been  mooted  in  at  least  one  State  and  would  have 
its  advantages. 

The  allowing  of  "conscientious  scruples"  to  exempt  one  from 
the  operation  of  such  laws,  as  is  the  case  in  Great  Britain,  emascu- 
lates the  law  and  renders  it  unw^orkable  under  American  conditions. 
A  law  of  this  kind  should  allow  no  exceptions,  beyond  permission 
to  allow  recovery  from  a  poor  state  of  health  before  vaccination,  and 
this  should  not  be  permitted  except  on  the  sworn  statement  of  a 
practising  physician.  Certificates  are  regarded  rather  lightly  by 
some  members  of  the  profession,  but  a  sworn  document,  with  the 
attendant  punishment  for  perjury,  would  not  be  given  unless  cir- 
cumstances fully  warranted  it. 

CHICKENPOX. 

Synonym. — Varicella. 

Definition. — An  acute  infectious  disease  of  children,  characterized 
by  an  eruption  of  vesicles  on  the  skin. 

Etiology. — This  disease  is  ordinarily  epidemic  but  is  occasionally 
sporadic  in  prevalence.  It  is  a  disease  of  childhood,  attacking  by 
preference  between  the  second  and  sixth  vears.  but  adults  who  have 
not  had  the  disease  are  sometimes  attacked.  There  is  no  known 
relation  between  chickenpox  and  smallpox,  an  attack  of  the  one  not 
conferring  any  immunity  against  the  other.  The  cause  is  as  yet 
unknown. 

Incubation. — 10  to  15  days. 


92  PRACTICAL   SANITATION. 

Symptoms. — The  first  symptom  is  fever,  slight  in  degree,  some- 
times preceded  by  a  light  chill  or  rarely  by  convulsions.  There 
may  be  vomiting  and  pain  in  the  back  and  legs.  The  eruption  is 
ordinarily  first  seen  on  the  trunk,  either  on  the  back  or  chest. 
More  rarely  it  begins  on  the  forehead  or  face.  Red  raised  papules 
appear  first,  generally  within  24  hours  of  the  first  symptoms.  In 
a  few  hours  these  change  to  hemispherical  vesicles  containing  fluid, ' 
either  clear  or  turbid.  At  the  end  of  36  or  48  hours  from  the  be- 
ginning of  the  attack,  the  vesicles  are  transformed  into  pustules 
which  are  usually  also  hemispherical,  but  may  be  flattened  or  even 
umbilicated.  In  a  few  more  hours  these  pustules  begin  to  dry  and 
shrivel,  and  by  the  end  of  the  third  or  fourth  day  are  converted 
into  dry  crusts  which  fall  of£  and  ordinarily  leave  no  scar. 

Varieties. — Varicella  Bullosa. — The  vesicles  become  large  and  de- 
velop into  blebs,  like  those  of  ecthyma  or  pemphigus.  If  scratched, 
these  lesions  are  liable  to  develop  into  ugly  and  troublesome  ulcers. 
This  is  more  liable  to  occur  since  the  blebs  itch  and  burn  badly. 

Varicella  Hemorrhagica. — This  has  been  described  as  occurring 
with  hemorrhages  from  mucous  membranes  and  under  the  skin. 

Varicella  Escharotica. — In  delicate  children,  particularly  the  tu- 
berculous, gangrene  of  the  skin  surrounding  the  pocks  or  of  other 
parts,  as  the  scrotum,  sometimes  is  seen. 

Complications. — Nephritis  may  follow  chickenpox. 

Infantile  Hemiplegia  has  been  observed. 

Diagnosis. — Ordinarily  easy,  especially  if  the  case  has  been  seen 
from  the  beginning.  Cases  in  adults  may  be  very  severe  and  simu- 
late smallpox  closely.  In  these  cases  history  of  exposure  to  small- 
pox or  the  reverse  throw  much  light  on  the  case.  If  in  doubt, 
vaccinate  the  contacts  and  call  it  smallpox  until  the  contrary  is 
proved. 

Mortality. — Usually  trifling ;  deaths  being  very  rare. 

Quarantine. — None  except  for  school-children.  The  patient  must 
be  isolated  for  14  days  or  longer,  until  desquamation  is  complete. 
Contact  children  must  be  excluded  from  school  for  14  days  if  not 
immune  through  a  previous  attack. 

SCARLET  FEVER. 

Synonyms. — Scarlatina;  Scarlet  Rash. 

Definition. — An  infectious  disease  of  unknown  etiology  charac- 


THE   EXANTHEMATA.  93 

terized  by  a  diffuse  eruption  on  the  skin  and  a  sore  throat  of  vary- 
ing intensity. 

Distribution. — Endemic  in  most  large  cities  in  the  temperate 
zone,  and  becoming  epidemic  in  all  localities  in  the  same  latitudes 
at  times. 

Etiology. — The  specific  germ  is  unknown,  although  streptococci 
are  found  with  great  constancy. 

Pathology. — There  are  no  constant  anatomical  changes.  The 
rash  does  not  persist  after  death  except  in  hemorrhagic  cases. 
Other  lesions  found  are  partly  due  to  high  temperature  and  partly 
to  associated  pus  organisms. 

Predisposing  Factors.- — Age  under  10  years;  90  per  cent  of  the 
fatal  cases  are  under  that  age;  nurslings,  however,  are  seldom  at- 
tacked. Susceptibility  to  scarlet  fever  is  less  general  than  to 
measles.  Family  susceptibility  is  sometimes  seen,  when  several 
members  of  a  single  family  may  die  in  rapid  succession. 

Mode  of  Infection. — Not  certainly  known,  but  nose  and  throat 
secretions,  scales  from  the  skin  and  pus  from  a  suppurating  ear 
have  all  been  known  to  convey  it.  It  is  certainly  infectious  at  a 
very  early  stage. 

Incubation. — Usually  from  2  to  4  days;  occasionally  24  hours 
and  sometimes  as  long  as  12  days. 

Prodromes. — Not  generally  noticeable. 

Onset. — Usually  sudden;  vomiting  is  a  very  constant  symptom; 
the  fever  is  intense,  often  reaching  105°  the  first  day;  skin  dry  and 
very  hot  to  the  touch ;  tongue  furred  and  dryness  of  the  throat  may 
be  complained  of ;  the  face  is  often  flushed  and  the  patient  appears 
"feverish."     Cough  and  catarrhal  symptoms  are  not  usually  seen. 

Eruption. — On  the  second  day,  but  occasionally  on  the  first,  the 
eruption  appears  in  the  shape  of  scarlet  points  under  the  skin. 
This  may  also  appear  in  the  roof  of  the  mouth,  even  before  it  shows 
on  the  skin.  In  typical  cases  the  skin  becomes  an  intense  diffuse 
scarlet  "like  red  flannel"  and  the  nail  drawn  over  the  skin  causes 
an  anemic  white  line,  followed  in  a  few  seconds  by  a  more  intensely 
red  one.  The  skin,  at  first  smooth,  becomes  rough  and  after  a  day 
or  so,  like  "goose-flesh."  The  eruption  may  not  be  uniform,  but 
patchy,  with  areas  of  normal  skin  intervening.  It  may  also  be 
indistinguishable  except  on  the  most  careful  observation,  and  may  be 
very  evanescent. 


94  PRACTICAL   SANITATION. 

Minute  hemorrhages  or  large  purpuric  spots  may  be  seen  in  the 
severe  and  malignant  forms.  The  whole  skin  may  be  covered  with 
little  yellow  vesicles  on  a  deep  background,  so-called  scarlatina 
miliaris.  There  may  be  tiny  papular  eruptions,  but  more  rarely 
than  in  measles.     The  rash  disappears  by  the  seventh  or  eighth  day. 

Mucous  Membranes. — The  tongue,  which  is  at  first  red  at  the  tip 
and  edges  and  elsewhere  furred,  soon  shows  the  reddened  papillae 
pushing  through  the  fur  to  form  the  rather  characteristic  "straw- 
berry" tongue.  In  a  few  days  the  fur  is  cast  off  and  the  tongue 
then  looks  like  a  red  raspberry.  This  enlargement  of  the  papillae 
of  the  tongue  was  the  only  constant  sign  in  1,000  cases  of  scarlet 
fever  (McColom). 

The  pharynx  shows  symptoms  grading  all  the  way  from  a  slight 
redness  to  an  intense  angina  with  false  membrane  accompanied  by 
glandular  swelling  or  even  in  the  severest  cases  a  thick  brawny  in- 
duration of  all  the  tissues  of  the  neck. 

Symptoms. — The  temperature  may  reach  anywhere  from  103° 
in  the  milder  cases  to  106°  in  the  severer  ones,  and  even  108°  and 
109°  have  been  recorded  before  death. 

The  pulse  ordinarily  ranges  from  120°  to  150°,  but  in  the  severest 
cases  with  high  fever  may  go  up  to  190°  or  200°. 

There  is  a  sudden  leucocytosis,  reaching  18,000  to  40,000.  After 
the  initial  vomiting,  the  stomach  symptoms  subside  and  generally 
give  no  further  trouble. 

Albuminuria  should  be  looked  for  every  day. 

Varieties. — Mild  form. — In  this  form  the  skin  eruption  if  present 
is  very  evanescent,  the  child  showing  only  a  slight  sore  throat.  This 
is  the  form  which  makes  so  much  trouble  for  the  sanitarian,  as 
people  will  not  believe  either  that  it  is  scarlet  fever  or  that  is 
infectious.  Nevertheless  it  may  give  rise  to  the  next  form  in  any 
child  who  may  come  in  contact  with  it. 

Malignant  Form. — Death  may  occur  within  24  or  36  hours  with 
every  symptom  of  an  overwhelming  intoxication;  the  temperature 
may  go  to  108°  or  109°,  with  convulsions  and  delirium,"  great  diffi- 
culty in  breathing,  very  rapid  and  feeble  pulse,  and  death  may  occur 
even  before  the  appearance  of  the  rash. 

Hemorrhagic  Form. — There  are  hemorrhages  into  the  skin,  nose 
bleed,  and  bloody  urine.  While  this  form  more  usually  attacks 
feeble  children,  it  sometimes  occurs  in  adults  of  previously  good 
health. 


THE   EXANTHEMATA.  95 

AnginosG  Form. — Throat  symptoms  appear  early  with  great  swell- 
ing of  fauces  and  tonsils  which  are  rapidly  covered  with  a  grayish 
exudate,  which  may  extend  into  pharynx,  larynx,  nose  and  mouth, 
and  occasionally  into  the  Eustachian  tube,  trachea  and  bronchi. 
There  may  be  death  of  the  tissues  and  sloughing.  Death  is  either 
by  toxemia  or  exhaustion. 

Desquamation. — Desciuamation  usually  begins  on  the  tenth  day. 
The  peeling-off  process  lasts  from  10  days  to  7  or  8  weeks.  The 
scales  maj'  be  small  and  ''branny"  or  entire  casts  of  a  finger  or  toe. 
It  seems  to  bear  some  relation  to  the  severity  of  the  disease,  and 
what  are  apparently  second  desquamations  have  been  known  to 
occur.  Sometimes  the  nails  and  hair  are  also  shed  with  the  epi- 
dermis. 

Complications. — Nephritis. — This  may  begin  in  the  second  week 
or  may  be  delaj^ed  to  the  fourth.     It  is  in  three  grades : 

(1.)  Acute  hemorrhagic  nephritis. — There  may  be  suppression 
of  urine  or  only  a  small  quantity  of  bloody  fluid  loaded  with  al- 
bumin and  casts ;  there  is  vomiting,  which  is  accompanied  by  severe 
uremic  convulsions  and  followed  by  death. 

(2.)  Acute  nephritis. — The  symptoms  are  less  urgent  in  this  non- 
hemorrhagic  form.  The  urine  is  diminished  in  quantity,  smoky  in 
color;  shows  albumin,  tube-casts,  a  few  blood  cells,  and  some  blood 
pigment.  The  eyelids  and  ankles  are  puffy,  and  there  may  be 
effusion  into  the  serous  sacs.  This  condition  may  drag  on  and  be- 
come chronic,  undergo  a  rapid  exacerbation  with  uremia  and  a  fatal 
termination,  or  undergo  resolution  as  it  generally  does. 

(3.)  Suh-acute  nephritis. — The  urine  contains  albumin  and  a  few 
casts,  but  rarely  blood.  The  constitutional  symptoms  are  mild  and 
recovery  is  scarcely  retarded.  Even  in  this  type  serious  symptoms, 
such  as  edema  of  the  glottis  or  rapid  pleural  effusion  may  occasion- 
ally supervene. 

In  either  of  these  last  two  types  recovery  may  be  slow,  the  child 
remaining  anemic  with  possibly  a  little  albumin  in  the  urine,  and 
the  condition  may  eventually  clear  up  or  pass  over  into  interstitial  or 
chronic  parenchymatous  nephritis. 

Arthritis. — This  is  of  two  types;  the  first  being  a  pyemia  with 
suppuration  of  one  or  more  joints,  which  is  a  very  serious  and  often 
fatal  form.  The  second  is  the  true  scarlatinal  rheumatisln,  anal- 
ogous to  gonorrheal  rheumatism,  which  may  attack  many  joints  at 
once  or  in  succession.     It  comes  on  in  the  second  or  third  week. 


96  PRACTICAL   SANITATION, 

There  may  be  purpura,  chorea,  heart  lesions  or  pleurisy.  In  this 
form  the  prognosis  is  generally  good. 

Heart  Lesions. — Like  the  joint  troubles,  these  are  of  two  kinds — 
the  malignant  endocarditis  sometimes  with  purulent  pericarditis 
which  are  rapidly  fatal,  and  the  simple  endocarditis  and  pericarditis 
which  often  undergo  complete  resolution.  There  is  also  a  toxic  in- 
flammation of  the  heart-muscle  which  is  occasionally  encountered 
and  which  is  rapidly  fatal. 

Chest  Lesions. — These  are  uncommon,  except  empyema,  which  is 
an  insidious  and  dangerous  complication. 

Ear  Lesions. — These  are  very  common  and  very  serious,  iirst  from 
the  damage  to  the  ear  itself,  with  resulting  deafness,  and  second, 
from  the  danger  of  extension  to  the  mastoid  and  meninges  or  to  the 
brain  itself.  There  may  be  paralysis  from  involvement  of  the  facial 
nerve. 

Glands. — There  may  be  an  inflammation  of  the  lymph-glands  of 
the  neck  of  any  degree  from  transitory  swelling  to  severe  suppura- 
tion or  long-standing  and  brawny  massive  swelling. 

Clioroa. — Chorea  may  follow  scarlet  fever,  as  may  sudden  or  pro- 
gressive paralyses. 

Relapses. — Relapses  were  noted  in  7  per  cent  of  12,000  cases  and 
in  1  per  cent  of  1,520. 

Differentiate. — From  acute  exfoliating  dermatitis ;  measles ;  Ger- 
man measles ;  septicemia ;  diphtheria ;  drug  rashes. 

Diagnosis. — The  most  reliable  diagnostic  signs  are  the  sudden  on- 
set; vomiting;  white  line  followed  by  red  when  anything  is  drawn 
sharply  over  the  skin;  punctate  eruption  in  the  mouth;  sudden 
fever;  strawberry  tongue;  high  leucocytosis.  It  must  be  remem- 
bered that  any  or  all  of  these  may  be  absent.  A  new  sign  recently 
observed  by  Bastia  of  Bucharest,  but  not  as  yet  confirmed,  is  the 
presence  of  two  or  three  bright  red  lines  in  the  bend  of  the  elbow 
very  early  in  the  disease.  lie  claims  that  this  is  constant  in  scarlet 
fever,  and  not  found  in  anything  else.     It  should  be  looked  for. 

Coexistent  Diseases. — Diphtheria,  chickenpox,  whooping  cough, 
measles,  erysipelas,  typhoid  and  typhus  have  been  noted  in  con- 
nection with  scarlet  fever. 

Mortality. — ^From  5  to  10  per  cent  in  mild  epidemics  and  from 
20  to  30  per  cent  in  severe  ones.  One  thousand  cases  in  the  Boston 
City  Hospital  gave  9.8  per  cent. 

Persistence  of  Infection. — 15,000  cases  in  Glasgow  isolated  49 


THE   EXANTHEMATA.  97 

days  or  under  showed  a  percentage  of  "return  eases"  from  the 
same  families  of  1.86  per  cent;  from  50  to  56  days,  1.12  per  cent; 
from  57  to  65  days,  1  per  cent. 

Quarantine  for  Contacts. — 12  days.  If  possible  non-immunes 
should  be  isolated  in  another  house. 

Quarantine  for  Convalescents. — Until  desquamation  is  absolutely 
complete,  a  minimum  of  21  days  and  a  maximum  of  8  weeks;  with 
a  running  ear,  the  child  should  be  excluded  from  school  much 
longer  than  8  weeks  and  should  under  no  circumstances  return 
to  school  under  5  weeks.  In  most  states  the  quarantine  is  of  the 
modified  degree.  Treatment  in  a  special  hospital  is  most  desirable 
from  a  sanitary  as  well  as  a  medical  point  of  view. 

Disinfection. — Before  discharge  from  quarantine  patient  should 
be  given  antiseptic  batlis  on  two  successive  days,  after  which  the 
disinfection  proceeds  in  the  ordinary  manner.  Formaldehyd  is 
the  preferred  disinfectant. 

Community  Prophylaxis. — School  inspection  daily,  restriction 
of  attendance  of  children  at  public  gatherings,  careful  administra- 
tion of  quarantine  and  scrupulously  careful  disinfection  are  the 
main  reliance  in  the  control  of  scarlet  fever.  Medical  attendants 
must  not  take  surgical  or  obstetrical  cases.  Funerals  must  be  pri- 
vate, and  the  dead  must  be  buried  within  24  hours.  They  must 
not  be  shipped  to  other  places  except  under  the  most  stringent 
precautions. 

Sera. — Various  antistreptococcic  sera  have  been  recommended 
for  prophylaxis  and  treatment.  In  severe  epidemics  they  are 
worth  trying,  not  as  a  means  to  prevent  the  primary  infection  but 
to  cut  short  the  secondary  infection.  It  should  not  be  forgotten 
that  a  rash  may  follow  the  injection  of  horse  serum  which  may  be 
confounded  with  scarlet  fever. 

MEASLES. 

Synonyms. — Morbili;  Kubeola. 

Definition. — An  acute,  highly  contagious  fever  with  specific 
localization  in  the  upper  passages  and  in  the  skin.     (Osier.) 

Etiology. — The  specific  cause  of  this  disease  is  unknown.  Re- 
cent experiments  on  monkeys  have  demonstrated  that  the  virus  is 
filtrable  through  porcelain  bougies  capable  of  holding  back  all 
known  bacteria. 


98  PRACTICAL   SANITATION. 

Direct  contagion  is  probably  the  only  method  of  transmission 
and  infectivity  is  probably  lest  by  the  time  convalescence  is  reached. 
The  nasal  and  bronchial  secretions  alone  seem  to  carry  the  virns,  the 
scales  havinu-  been  found  non-pathogenic  for  monkeys  even  at  the 
height  of  the  disease.  Infection  by  fomites  is  according  to  our 
present  knowledge  impossible. 

An  important  point  to  remember  is  that  it  is  contagious  some- 
times two  or  three  days  before  the  breaking-out  of  the  eruption, 
being  evidenced  only  by  the  slight  catarrh  of  the  respiratory  pas- 
sages and  a  slight  redness  of  the  eyes. 

Susceptibility  to  measles  is  universal  in  childhood  and  among 
adults  who  have  not  had  the  disease  in  childhood.  Infants  under 
the  age  of  three  months  have  a  relative  immunity,  but  children 
may  be  born  vnth  the  measles  eruption  or  develop  it  within  a  few 
days  after  birth. 

This  disease  is  more  dreaded  than  smallpox  by  military  and  in- 
stitutional sanitarians  because  of  the  difficulty  of  taking  effective 
measures  against  it. 

Pathology. — The  catarrhal  and  inflammatory  changes  have  noth- 
ing characteristic.  The  fatal  cases  are  usually  killed  by  broncho- 
pneumonia and  intense  bronchitis.  The  lymphatic  elements  all 
over  the  body  are  swollen.  During  convalescence  previously  la- 
tent tuberculosis  is  liable  to  become  active. 

Incubation. — From  7  to  18  days,  oftenest  14.  No  special  symp- 
toms are  to  be  observed  during  this  period. 

Onset. — For  3  or  4  days,  sometimes  a  day  or  two  longer,  the  child 
presents  the  features  of  a  feverish  cold.  The  onset  may  be  in- 
sidious or  more  rarely  abrupt  with  even  a  convulsion.  There  is 
rot  often  a  definite  chill.  Severe  cases  may  begin  with  headache, 
nausea  and  vomiting.  The  fever  is  slight  at  first  but  becomes  burn- 
ing, with  congestion  of  the  skin.  The  catarrhal  symptoms  are  ex- 
aggerated, vidth  running  nose,  coughing  and  sneezing,  redness  of 
eyes  and  lids,  and  avoidance  of  the  light.  There  may  be  a  pre- 
liminary eruption  of  flat  red  spots  or  blotches  on  the  skin,  but 
this  is  unusual.  The  tongue  is  furred  and  the  mucous  membrane 
of  the  mouth  reddened.  The  fever  may  rise  abruptly  but  more 
frequently  takes  24  to  48  hours  to  reach  its  height.  The  pulse-rate 
runs  high,  up  to  140  or  160  per  minute,  declining  with  the  fever. 

Eruption. — Sydenham's  classical  description  cannot  be  im- 
proved upon.     "The  symptoms  increase  till  the  fourth  day.     At 


THE   EXANTHEMATA.  99 

that  period  (although  sometimes  a  day  later)  little  red  spots,  just 
like  flea-bites  begin  to  come  out  on  the  forehead  and  the  rest  of 
the  face.  These  increase,  both  in  size  and  number,  and  mark  the 
face  with  largish  red  spots  of  different  figures.  These  red  spots 
are  formed  by  small  red  papules,  thick  set,  and  just  raised  above 
the  level  of  the  skin.  The  fact  that  they  really  protrude  can 
scarcely  be  determined  by  the  eye.  It  can,  however,  be  deter- 
mined by  feeling  the  surface  with  the  fingers.  From  the  face, 
where  they  first  appear,  these  spots  spread  downward  to  the  breast 
and  belly;  afterward  to  the  thiglis  and  legs."  The  papules  are 
rather  shotty  in  feel,  but  do  not  extend  deeply.  The  color  of  the 
eruption  is  less  uniform  and  the  swelling  of  the  skin  is  less  intense 
on  the  trunk  and  extremities.  On  the  other  hand,  the  mottled 
blotchy  character  of  the  eruption  is  more  marked  on  the  chest  and 
abdomen.  The  eruption  is  hyperemic  and  tends  to  disappear  on 
pressure  except  in  malignant  cases,  in  which  it  is  deep  rose  or 
purple,  and  does  not  disappear. 

The  general  symptoms  do  not  much  abate  with  the  appearance 
of  the  eruption,  but  persist  until  the  end  of  the  fifth  or  sixth  day. 
Miliary  vesicles  or  petechia3  are  occasionally  seen.  The  "reces- 
sion" of  the  rash  which  was  formerly  considered  the  cause  of  death 
in  measles  is  interpreted  hy  Osier  to  be  merely  a  sign  of  the  fail- 
ing circulation  which  really  causes  death. 

Koplik's  Spots. — These  are  white  or  bluish-white  spots,  sur- 
rounded by  red  areola,  on  the  inside  of  the  cheek  opposite  the 
line  of  closure  of  the  teeth.  They  are  extremely  constant  and  are 
to  be  found  even  before  the  appearance  of  the  rash.  They  should 
be  looked  for  in  a  good  natural  light,  and  the  sanitarian  should 
familiarize  himself  with  their  appearance. 

Eosinophilia. — In  doubtful  cases  of  measles,  the  presence  of  a 
distinct  eosinophilia  may  help  to  clear  up  the  diagnosis,  if  facilities 
for  a  blood  examination  are  at  hand. 

Desquamation. — The  desquamation  is  in  fine  scales,  more  rarely 
in  large  flakes.  It  is  in  proportion  to  the  extent  and  severity  of 
the  rash.  Its  completion  may  take  a  few  days  only  or  extend  to 
several  weeks. 

Atypical  Forms. — Attentuated. — The  child  is  well  by  the  fifth 
day. 

Abortive. — The  initial  symptoms  are  present,  but  no  eruption 
follows. 


100  rUACTICAL   SANITATION. 

]\Ialignant,  Black,  or  Hemorrhagic. — This  occurs  most  fre- 
quently in  large  epidemics  and  in  institutions,  and  in  children  rather 
than  adults.  Hemorrhages  occur  in  the  skin  and  mucous  membranes, 
and  from  mucous  membranes;  there  is  very  high  fever  and  all  the 
symptoms  of  the  most  profound  intoxication  are  present,  v^^ith 
cyanosis,  difficult  respiration,  and  heart  weakness.  Death  occurs 
from  the  second  to  the  sixth  day. 

Complications. — Nose-bleed. — Sometimes  a  serious  complication. 

Laryngitis. — Not  uncommon ;  the  voice  is  husky  and  the  cough 
croupy. 

Bronchitis  and  Broncho-pneumonia.— The  bronchitis  is  so  con- 
stant as  to  be  an  integral  part  of  the  disease,  and  the  possibility 
of  its  extension  to  the  bronchioles  must  always  be  borne  in  mind. 
Broncho-pneumonia  is  the  cause  of  the  greater  part  of  the  mortality 
in  measles. 

Lobar  pneumonia. — This  is  less  common  than  the  foregoing. 

Parotitis  occurs  occasionally. 

Gangrenous  stomatitis  is  sometimes  seen,  especially  in  run-down 
children  in  institutions.  It  is  a  frightful  condition  in  which  death 
is  less  to  be  feared  than  recovery. 

Diarrhea  is  a  very  troublesome  feature  of  some  epidemics. 

Nephritis  occurs  less  frequently  than  after  scarlet  fever,  but  more 
commonly  than  usually  thought.     The  urine  should  be  watched. 

Whooping  cough  occurring  with  or  following  measles  is  a  compli- 
cation to  be  dreaded. 

Other  rare  complications  occur,  for  which  the  reader  is  re- 
ferred to  any  standard  work  on  pediatrics  or  practice. 

Prognosis. — This  disease  ranks  third  in  death-rate  among  the 
eruptive  fevers.  The  case  death-rate  is  not  high,  but  owing  to  the 
large  number  of  cases  and  the  wide-spread  susceptibility  to  the  dis- 
ease, the  total  is  very  large.  The  death-rate  is,  however,  not  so 
much  due  to  the  measles  as  to  the  complications.  In  a  virgin  soil 
the  proportion  of  deaths  is  frightful,  as  in  the  Fiji  Islands  where  40,- 
000  out  of  150,000  inhabitants  died  in  four  months. 

Immunity. — Immunity  is  almost  invariably  conferred  by  one  at- 
tack, and  so-called  second  attacks  are  nearly  always  due  to  mistakes 
in  diagnosis. 

Diagnosis. — During  the  prevalence  of  an  epidemic  the  disease  is 
easily  recognized,  but  mistakes  occur,  as  for  instance  in  the  sending 
of  measles  cases  to  smallpox  hospitals.     Usually  the  isolation  of 


THE   EXANTHEMATA.  101 

the  patient  and  observation  of  the  development  of  the  eruption  for 
a  few  hours  will  settle  the  question  definitely  one  way  or  the  other. 
Koplik's  spots  and  the  eosinophilia  should  not  be  forgotten.  Co- 
paiba and  antidiphtheritic  serum  give  a  rash  much  like  that  of 
measles,  but  antipyrin,  chloral  and  quinine  rashes  ordinarily  pre- 
sent no  difficulty.     Malignant  measles  may  resemble  typhus  also. 

Prophylaxis. — This  is  a  most  difficult  disease  to  handle,  as  the 
long  period  of  incubation  and  the  four  days  of  infectiousness  before 
the  eruption  appears,  together  with  the  refusal  of  the  laity  to  regard 
it  seriously,  conspire  to  render  its  conduct  almost  impossible.  The 
sanitarian  and  school  inspector  must  take  every  opportunity  to 
educate  the  public  to  the  fact  that  measles  is  a  serious  disease, 
that  it  is  early  infectious,  that  suspicious  cases  must  be  isolated 
without  waiting  for  the  eruption,  and  that  the  isolation  must  be 
thorough. 

Quarantine. — For  contacts,  18  days;  for  the  sick,  at  least  that 
length  of  time,  and  as  much  longer  as  for  the  entire  completion 
of  desquamation  and  the  subsidence  of  the  catarrhal  conditions. 
After  release  from  quarantine  the  child  should  not  be  allowed  to 
re-enter  school  for  at  least  5  days  longer. 

Disinfection. — Disinfection  is  very  eertainl}^  an  unnecessary 
trouble  and  expense. 

RUBELLA. 

Synonyms. — Rotheln;  German  Measles;  French  Measles;  Epi- 
demic Roseola;  Rubeola  notha. 

Etiology. — This  acute  infectious  disease  is  of  unknown  causation, 
spreads  with  great  rapidity,  frequently  attacks  adults,  and  previous 
attacks  of  scarlet  fever  or  measles  do  not  protect  against  it. 

Symptoms. — The  stage  of  incubation  is  supposed  to  be  two  weeks 
or  more.  The  symptoms  are  much  milder  than  those  of  measles  in 
most  epidemics ;  very  rarely  they  may  be  severe. 

In  the  stage  of  invasion  there  are  chilliness,  headache,  pains  in 
back  and  legs,  and  coryza.  A  rose  red  spotty  eruption  on  the 
pharynx  and  fauces  is  a  constant  symptom.  There  may  be  slight 
fever,  frequently  not  reaching  over  100°,  or  absent  altogether. 
This  stage  is  variable  in  length,  being  placed  by  different  authors 
at  from  1  to  3  days.  The  eruption,  which  consists  of  round  or  oval 
slightly  elevated  spots,  usually  discrete  but  sometimes  confluent, 


102  PRACTICAL   SANITATION. 

appears  first  on  the  face,  then  on  the  chest  and  later  over  the  whole 
body  in  the  course  of  24  hours.  The  rash  is  brighter  colored  than 
that  of  measles.  The  patches  are  less  crescentic.  The  eruption 
lasts  2  or  3  days,  sometimes  longer,  and  gradually  fades,  and  is 
followed  by  rather  powdery  desquamation.  The  lymph  glands  of 
the  neck  are  enlarged  quite  constantly,  and  if  the  eruption  is  severe 
those  of  other  parts  of  the  body  may  be  also. 

Albuminuria,  nephritis,  jaundice,  colitis  and  pneumonia  are  oc- 
casional sequelae  of  this  disease,  but  not  with  sufficient  frequency 
to  determine  whether  they  are  causally  related  or  not. 

Prophylaxis. — Not  usually  taken  notice  of  by  sanitarians  as  it  is 
ordinarily  a  trivial  disease.  In  severe  epidemics  it  would  be  best 
to  treat  the  cases  as  though  they  were  scarlet  fever. 

FILATOW-DUKES'  DISEASE. 

Synonym. — Fourth  Disease. 

By  certain  writers  it  is  claimed  that  two  different  diseases  have 
been  confused  under  the  name  rubella.  In  this  second  form  the 
body  is  covered  in  a  few  hours  with  a  diffuse  eruption  of  a  bright 
red  color,  almost  like  that  of  scarlet  fever.  The  face  may  remain 
free.  It  is  chiefly  of  interest  owing  to  the  possibility  of  confusion 
with  scarlet  fever.     The  symptoms  are  otherwise  trifling. 


CHAPTER  VIII. 

THE  DIPHTI-IERIA  GROUP. 

This  is  a  small  but  very  important  group,  whose  members  have 
in  common  a  great  susceptibility_to  trapsmission  by  droplet  infec- 
tion and  not  very  great  liability  to  transmission  by  other  mean^. 
Carriers  of  influenza,  whooping  cough  and  diphtheria  are  common, 
and  may  be  suspected  for  mumps.  Pneumonia  also  belongs  to  this 
class  but  is  omitted  for  the  reason  that  in  the  present  state  of  our 
knowledge  concerning  this  disease  it  cannot  be  said  what  measures 
possible  to  the  sanitarian  will  ever  be  able  to  control  it.  All  the 
diseases  in  this  groiip_a£fi-pritQflT-ily  fpim^  ^^  ^hp  rpppiratory  tract  or 
its  adnexa.  In  addition,  diphtheria  may  infect  the  conjunctiva  or 
genitalia. 

DIPHTHERIA. 

Synonym. — Membranous  Croup. 

Definition. — A  specific  infectious  disease,  characterized  by  a  local 
fibrinous  exudate,  usually  upon  a  mucous  membrane,  and  by  con- 
stitutional disturbance  due  to  toxins  produced  at  the  site  of  the 
lesion  (Osier).  The  presence  of  the  Klebs-Loffler  bacillus  is  a 
necessary  factor  in  true  diphtheria,  and  it  may  be  present  without 
any  of  the  ordinary  symptoms  of  diphtheria.  On  the  other  hand, 
a  precisely  similar  exudate  may  be  present  without  the  bacillus 
above  named.     (Vincent's  angina,  page  107.) 

Habitat. — World  wide.  Endemic  in  large  centers  of  population, 
becoming  epidemic  frequently,  and  pandemic  in  cycles. 

Etiolog"y. — Favored  by  dry  seasons,  and  more  prevalent  in  au- 
tumn. 

Modes  of  Infection. — The  disease  is  highly  contagious,  being 
particularly  fatal  to  physicians  and  nurses;  it  may  be  conveyed  by 
infected  articles ;  it  is  also  frequently  traced  to  ' '  carriers, ' '  in  whom 
it  is  the  cause  of  persistent  suppuration  of  the  ear  or  nasal  sinuses, 
or  tonsillitis,  or  may  cause  no  discoverable  symptoms,  being  recov- 
ered from  the  nasal  or  throat  secretions  of  apparently  healthy  indi- 
viduals. These  carriers  may  or  may  not  have  had  a  preceding 
attack  of  frank  diphtheria.    Pencils,  cups  or  other  articles  con- 

103 


104  PEACTICAL  SANITATION. 

taminated  with  the  secretions  of  such  persons  have  frequently 
carried  the  disease.  Milk  is  also  an  excellent  vehicle  for  the  infec- 
tion, and  occasionally  dust  or  domestic  animals  have  been 
held  responsil)le,  though  perhaps  on  insufficient  grounds. 

Air-borne  infections  from  defective  drains,  sewer  gas,  etc.,  are 
not  believed  to  occur.  The  disease  may  also  be  conveyed  by  direct 
inoculation. 

Predisposing  Causes. — Diphthma  occurs  at  ^^^  ^^^^j  ^^""^  ^'^^  Tnoat 
f]^|1ipilt  prop^^'ti^U^tpIy^H^twppn  thp  enrly  pni't  of  thr  ."rrond  nnr] 
close  of  the  fifth  years,  and  is  most  fatal  atJ.hose  a^s.  It  rarely 
occurs  in  infancy,  but  may  be  seen  in  the  new-born,  and  may 
be  seen  at  all  ages  to  the  other  extreme  of  life.  Girls  are 
attacked  slightly  more  frequently  than  ^bo^^s.  Individual  sus- 
ceptibility varies.  jMost  of  those  exposed  are  attacked,  but  some 
escape  even  of  those  in  whose  threats  or  noses  virulent  bacilli  are 
found. 

The  Klebs-Loffler  Bacillus. — This  bacillus  is  non-motile,  from 
2.5  to  3  mi.  in  length  and  from  0.5  to  0.8  mi.  in  thickness.  Its 
recognition  and  special  characteristics  will  be  dealt  with  in  the 
special  chapter  on  Laboratory  Methods  (page  367).  It  varies 
greatly  in  virulence,  even  to  almost  complete  harmlessness.  Its 
noxious  action  is  due  to  one  or  several  toxins,  which  act  on  the 
heart  muscle,  causing  fatty  degeneration ;  on  the  kidneys,  causing 
nephritis ;  on  the  nervcus  system,  causing  paralysis. 

Pathology. — The  false  membrane  in  fatal  cases  is  distributed  in 
the  order  of  frequency  as  follows :  larynx,  trachea,  tonsils,  epiglot- 
tis, pharynx,  nose,  uvula,  esophagus,  tongue,  stomach,  duodenum, 
vagina,  vulva,  conjunctiva. 

In  non-fatal  cases,  it  is  much  more  frequently  found  in  the 
pharynx  and  upon  the  tonsils.  It  may  be  found  on  the  skin  sur- 
face occasionally. 

This  membrane  is  a  dirty  gray  or  greenish  gray,  firmly  attached 
in  the  earlier  stages,  only  to  be  removed  by  the  use  of  considerable 
force  and  leaving  a  bleeding  surface  if  detached.  Later,  it  is  soft, 
shreddy,  and  easily  removed.  If  there  has  been  much  necrosis,  the 
parts  look  gangrenous.  The  lymphatic  glands  of  the  neck  are  en- 
larged especially  in  fatal  cases,  and  the  salivary  glands  may  be 
swollen.  Sometimes  the  diphtheritic  deposit  is  not  a  membrane, 
but  a  dirty  friable  exudate.  In  either  case  it  is  composed  of  the 
bacteria,  fibrin,  and  cast-off  epithelium,  and  the  primary  condition 


THE   DIPHTHERIA    GROUP.  105 

is  a  necrosis  of  the  superficial  tissues  of  the  throat  or  other  part 
attacked,  due  to  the  toxins  of  the  bacilli  there  growing.  The  bacilli 
grow  only  in  dead  tissue,  spreading  as  fresh  tissues  are  attacked  and 
killed  by  the  toxins. 

The  changes  in  other  organs  are  as  follows : 

Heart. — The  heart  is  frequently  attacked  by  fatty  or  hyaline  de- 
generation, and  the  heart  muscle  may  be  acutely  inflamed. 

Lungs. — The  lungs  are  often  the  seat  of  a  broncho-pneumonia,  in 
which  the  diphtheria  bacillus  may  be  associated  with  the  pneu- 
mococcus  or  streptococcus. 

Kidneys. — These  organs  are  often  attacked  by  an  acute  inflamma- 
tory process,  varying  from  a  simple  degeneration  to  the  most  intense 
nephritis. 

Incubation. — 2  to  7  days,  oftenest  two. 

Onset. — The  initial  symptoms  are  those  of  an  ordinary  febrile 
attack,  slight  chilliness,  fever,  and  pain  in  back  and  limbs.  In  mild 
cases  the  child  does  not  feel  ill  enough  to  want  to  go  to  bed.  The 
temperature  in  the  first  24  hours  usually  reaches  102.5°  or  103° 
and  in  severe  cases  to  104°.  As  in  other  acute  febrile  conditions, 
young  children  may  have  convulsions  at  the  onset. 

Symptoms. — Pharyngeal  Diphtheria. — In  a  typical  case  there 
is  at  first  a  slight  redness  of  the  throat  with  diificulty  in  swallowing. 
The  membrane  first  occurs  on  the  tonsils  and  may  be  hard  to  dis- 
tinguish at  first  from  the  exudate  of  the  tonsillar  follicles.  The 
tonsils  are  swollen.  By  the  third  day  the  whole  throat  including 
tonsils,  pillars  of  the  fauces  and  pharynx  is  covered  with  the  mem- 
brane. This  membrane  is  at  first  grayish-white,  but  later  becomes 
a  dirty  gray  or  greenish  or  yellowish-white.  If  removed,  the  base 
bleeds  and  is  soon  covered  again  by  the  membrane.  The  glands  in 
the  neck  are  swollen  and  tender;  the  temperature  is  in  uncompli- 
cated cases  about  as  recorded  above;  the  pulse  is  from  110°  to  120°. 
The  local  condition  in  the  throat  is  not  decidedly  severe  and  con- 
stitutional symptoms  are  slight.  The  symptoms  gradually  abate, 
the  swelling  of  the  glands  diminishes,  the  membrane  separates,  and 
from  the  seventh  to  the  tenth  day  the  throat  clears  up  and  conva- 
lescence is  established. 

Atypical  Forms. — Atypical  forms  of  pharyngeal  diphtheria  fall 
into  the  following  classes  (Koplik)  : 

(a)  No  membrane,  but  a  simple  croupy  cough. 

(b)  A  pulpy  exudate  on  tonsils,  but  no  membrane. 


106  PRACTICAL  SANITATION. 

(c)  A  punctate  membrane,  with  spots  isolated,  on  tonsils. 

(d)  Cases  which  are  apparently  follicular  tonsillitis,  at  least  in 
the  beginning,  but  later  there  may  be  a  true  membrane,  spreading 
to  other  parts  of  the  throat  or  to  the  nose. 

(e)  ''Latent  diphtheria"  (Heubner)  secondary  to  rickets  or 
tuberculosis,  with  fever,  naso-pharyngeal  catarrh  and  digestive  dis- 
turbances or  diarrhea.  The  true  cause  is  frequently  not  discovered 
until  autopsy. 

Systemic  Infection.^ — As  a  rule  the  constitutional  disturbances 
bear  a  direct  relation  to  the  local  severity  of  the  disease,  but  this 
rule  may  vary  in  either  direction.  In  the  grave  septic  conditions 
sometimes  seen,  there  is  a  general  infection  comparable  to  true 
septicemia.  They  usually  occur  at  the  height  of  the  pharyngeal 
infection,  and  are  accompanied  by  great  swelling  of  the  lym- 
phatics, great  prostration,  and  often  by  severe  sloughing  of  the 
diphtheritic  areas.  The  pulse  is  rapid  and  feeble,  and  the  tem- 
perature may  be  only  slightly  elevated  or  subnormal. 

Nasal  Diphtheria. — In  cases  of  this  kind,  the  Klebs-Loffier  bacillus 
is  found  in  the  nose,  with  or  without  a  membrane.  It  may  produce 
a  most  malignant  form  of  the  disease,  or  it  may  cause  Membran- 
ous or  Fibrinous  Rhinitis  in  which  the  nose  is  blocked  with  thick 
membranes  but  there  is  little  or  no  constitutional  disturb- 
ance. This  disease  is  benign,  but  a  prolific  source  of  infection  to 
others. 

Laryngeal  Diphtheria. — This  form  of  the  disease  is  always  due 
to  the  Klebs-Loffler  organism,  but  may  be  simulated  by  strepto- 
cpceic  infection  and  the  two  forms  may  coexist  as  in  a  personal  case. 
That  due  to  the  streptococcus  is  more  apt  to  be  secondary  to  other 
diseases. 

The  symptoms  due  to  obstruction  of  breathing  overshadow  other 
features.  The  disease  begins  like  an  acute  laryngitis,  but  after  a 
day  or  two  the  child  becomes  worse,  usually  at  night,  and  the  respira- 
tion becomes  obstructed.  The  obstruction  is  paroxysmal  at  first, 
but  soon  becomes  continuous,  and  the  accessory  muscles  of  respira- 
tion are  called  upon,  the  chest  moves  convulsively,  with  retraction 
of  the  epigastrium  and  lower  intercostal  spaces  are  retracted  with 
the  fight  for  air,  and  the  voice  sinks  to  a  whisper.  The  color  be- 
comes livid  from  imperfect  oxidation  of  the  blood,  and  the  child 
tosses  vainly  in  the  effort  to  breathe.  In  favorable  cases,  the  mem- 
brane is  loosened  and  coughed  up,  but  in  unfavorable  cases  the 


THE   DIPHTHERIA   GROUP.  107 

symptoms  grow  worse,  the  child  becomes  semi-comatose,  and  death 
is  caused  by  suffocation. 

Inspection  of  the  throat  may  show  a  membrane  in  the  pharynx  or 
on  the  fauces,  but  a  bacteriological  examination  is  required  to  de- 
termine the  offending  cause.  Even  bacteriological  methods  will  fail 
ill  a  heavy  percentage  of  eases,  according  to  Straus. 

Diagnosis. — The  true  diagnosis  can  only  be  made  in  any  form  of 
diphtheria  by  the  use  of  cultures  and  the  microscope,  for  which  see 
the  chapter  on  Lahoratory  Methods  (page  367). 

The  two  diseases  with  which  diphtheria  is  most  apt  to  be  con- 
founded are  Streptococcic  DiphtJieritis  which  is  due  to  infection  by 
the  streptococcus,  and  Vincent's  Angina,  an  ulcerative  condition 
of  the  throat,  with  a  greenish-yellow  exudate.  Constitutional  dis- 
turbances may  be  severe  in  either  form,  but  the  death-rate  is  not 
so  high  in  these  last  two  diseases.  The  recovery  of  the  streptococcus 
in  pure  or  nearly  pure  culture  from  the  first,  and  of  the  Bacillus 
fusiformis  from  the  latter  will  settle  the  question.  It  should  not 
be  forgotten  that  mixed  infections  of  the  Klebs-Loffler  bacillus  with 
other  forms  are  sometimes  seen. 

Complications. — Albuminuria  has  already  been  mentioned  as 
present  in  all  severe  cases.  Nephritis  may  occur  of  all  grades, 
sometimes  ushered  in  by  complete  suppression  of  the  urine. 

Paralysis  is  the  most  common  complication,  occurring  in  from 
10  to  20  per  cent  of  all  cases.  It  is  due  to  toxin  absorption  and  is 
capable  of  experimental  production  in  animals.  It  may  attack  al- 
most any  of  the  muscles,  but  is  more  frecj[uently  observed  in  the 
palate,  the  muscles  of  deglutition  and  the  eye  muscles.  It  usually 
disappears  in  two  or  three  weeks,  but  is  a  grave  complication  since 
the  death-rate  is  considerably  higher  in  paralyzed  patients.  The 
tendency  to  paralysis  is  lowered  by  the  use  of  antitoxin. 

Heart  irregularities  are  present  in  a  majority  of  all  severe  cases, 
as  evidenced  by  the  presence  of  a  murmur.  Cases  of  very  low 
pulse  rate  (30  to  40)  are  very  serious.  Death  may  ensue  from 
paralysis  of  the  vagus,  or  from  granular  or  fatty  degeneration  of 
the  heart  muscle. 

The  urticarial  eruption  ("nettle  rash")  caused  sometimes  by 
the  use  of  antitoxin,  and  which  is  an  effect  of  the  proteids  of  the 
horse  serum,  resembles  measles,  and  may  be  accompanied  by  pains 
and  slight  swelling  of  the  joints.  It  comes  on  8  or  10  days  after 
the  use  of  the  serum,  and  lasts  for  3  or  4  days. 


108  PRACTICAL   SANITATION. 

A  more  serious  condition  is  that  of  anaphylaxis  or  supersensi- 
tiveness  to  the  horse  serum,  which  is  sometimes  fatal  within  a  few 
minutes.  It  is  due  to  a  previous  small  injection  of  the  serum  or  to 
a  special  intolerance  to  horse  serum.  It  is  so  rare  that  its  occur- 
rence is  not  to  be  permitted  to  weigh  against  the  use  of  antitoxin 
for  a  moment. 

Antitoxin. — This  serum  is  prepared  by  repeatedly  injecting 
healthy  young  horses  with  filtered  toxins  of  diphtheria  bacilli.  It 
has  wonderfully  reduced  the  mortality  if  used  early  and  used 
upon  any  case  not  actually  dying  will  prove  of  great  assistance. 
It  has  been  used  in  a  dosage  of  many  thousands  of  units  in 
severe  cases,  and  the  aim  should  always  be  to  use  enough.  In  a 
dosage  of  500  to  1,000  units  it  is  used  for  the  immunization  of  con- 
tacts. 

Prognosis. — In  the  pre-antitoxin  days  the  mortality  from  true 
diphtheria  ran  as  high  as  40  to  50  per  cent.  In  the  same  hospitals 
since  the  introduction  of  antitoxin  .it  has  never  been  over  15  per 
cent  and  most  of  the  time  from  10  to  12  per  cent.  By  early  diag- 
nosis and  the  abundant  use  of  antitoxin  these  figures  may  be  still 
further  improved. 

Individual  Prophylaxis. — The  individual  is  best  protected  against 
diphtheria  by  care  of  the  throat  and  teeth  at  all  times.  During  epi- 
demics the  use  of  a  spray  of  corrosive  sublimate,  1  to  10,000,  or 
chlorine  water,  1  to  1,000,  or  Dobell's  solution  of  phenol  may  some- 
what aid.  As  already  mentioned,  the  prophylactic  use  of  the  anti- 
toxic serum  is  to  be  recommended,  especially  for  contacts  and  for 
physicians  and  nurses. 

Community  Prophylaxis. — Prompt  isolation  of  sick  and  of  sus- 
pects until  bacteriological  examination  has  shown  that  the  disease 
is  not  diphtheria.  Diphtheria  is  particularly  well  adapted  to  treat- 
ment in  contagious  disease  hospitals.  No  one  should  be  released 
from  the  quarantine,  even  if  not  apparently  sick,  until  cultures 
taken  from  the  throat  are  shown  to  be  negative.  The  dead  must  be 
cared  for  as  in  the  special  chapter  on  the  subject.  The  tendency  of 
the  bacilli  to  persist  in  throat  and  nose  long  periods  of  time  after 
convalescence  is  established  should  not  be  forgotten.  All  children 
and  to  a  lesser  degree  adults  who  have  been  in  contact  with  the 
disease  should  have  swabs  made  and  cultures  taken,  and  if  positive 
results  are  obtained,  must  be  isolated  until  negative  results  are  ob- 
tained, preferably  on  two  successive  days. 


THE    DIPHTHERIA   GROUP,  109 

Schick  or  Diphtherin  Reaction. — A  minute  quantity  of  the 
toxins  of  diphtheria  injected  into  the  deeper  layers  of  the  skin  gives 
a  hyperemia  at  the  end  cf  24  hours  in  all  persons  having  natural  or 
ae(|uired  immunity  to  diphtheria.  If  this  reaction  is  well  marked 
the  use  of  immunizing  doses  of  antitoxin  is  unnecessary.  It  is  apt 
to  l)e  partieularl.y  well  marked  in  carriers  and  furnishes  an  addi- 
tional method  for  their  detection.  This  test  is  to  be  had  commer- 
cially. 

Quarantine. — Of  the  modified  type.     The  length  of  time  is  de 
termined  by  the  results  of  cultures  made. 

Disinfection. — By  fumigation  with  formaldehyd  or  sulphur,  the 
former  being  preferable.  Exposure  for  at  least  six  hours  under 
standard  conditions  is  necessary  for  certain  results. 

Diphtheroid  Diseases. — Isolation  and  disinfection  in  Strepto- 
coccic Diphtheritis  and  Vincent 's  Angina  are  not  usually  considered 
necessary  in  private  practice  after  establishment  of  the  diagnosis, 
bii^  such  cases  must  be  excluded  from  school,  and  in  institutions 
are  best  isolated  and  their  quarters  disinfected. 

SEPTIC  SORE  THROAT. 

Definition. — This  name  is  usually  applied  to  Streptococcic  Diph- 
tJio-itis  but  for  public  health  purposes  should  also  include  Vincent's 
Angina.  It  is  marked  by  the  appearance  of  a  diphtheroid  mem- 
brane, \\dth  or  \^dthout  ulceration,  in  the  throat  and  fauces.  The 
temperature  may  or  may  not  be  high,  but  there  is  great  prostra- 
tion, and  also  much  pain  in  the  head,  back,  and  joints. 

Mode  of  Infection. — By  contact  and  frequently  in  contaminated 
milk  supplies. 

Prophylaxis. — As  for  diphtheria,  except  that  the  diphtheria  an- 
titoxin is  of  no  value. 

INFLUENZA. 

Synonym. — La  Grippe. 

Definition. — A  pandemic  disease,  appearing  at  irregular  inter- 
vals, characterized  by  rapid  spread  and  a  high  percentage  of  inci- 
dence wherever  it  occurs.  It  has  many  aspects,  but  shows  a  special 
tendency  to  attack  the  respiratory  tract.  For  several  years  after 
a  pandemic  it  remains  as  an  endemic,  epidemic  or  sporadic  disease. 

History. — During  the  Nineteenth  Century  there  were  four  pan- 
.  demies,  reaching  practically  every  part  of  the  world.  All  of  them 
appeared  to  start  in  the  Far  East. 


110  PRACTICAL   SANITATION. 

Etiology. — It  is  a  highly  infectious  disease,  attacking  usually 
about  40  per  cent  of  the  population.  It  is  caused  by  a  small  non- 
motile  bacillus,  which  stains  with  methylene  blue  (Loffler's)  and 
dilute  carbol-fuchsin  in  water,  the  Bacillus  influenzae,.  This  organ- 
ism grows  in  pure  culture  only  in  the  presence  of  hemoglobin, 
but  in  mixed  cultures,  for  instance  with  the  yellow  staphylococcus, 
flourishes  luxuriantly.  It  is  not  known  to  attack  domestic  animals. 
It  is  present  in  immense  numbers  in  the  nasal  and  bronchial  secre- 
-tion  of  patients,  and  in  the  latter  may  be  in  pure  culture. 

Catarrhal  Fever  (Grippe)  is  a  rather  similar  disease  which  is 
of  unknown  etiology,  and  is  endemic  in  American  cities. 

Incubation. — 1  to  4  days,  ordinarily  3  or  4. 

Types. — Respiratory. — In  this  form  the  mucous  membrane  of 
the  respiratory  tract  is  attacked.  There  are  coryza,  bronchitis, 
cough,  and  the  ordinary  symptoms  of  catarrhal  fever  but  with 
greater  pain  in  back,  limbs  and  head,  and  much  greater  prostra- 
tion. The  bronchitis  is  often  severe,  there  may  be  pleurisy,  or 
broncho-pneumonia  may  supervene.  This  pneumonia  may  be  the 
result  of  the  infection  by  the  influenza  bacillus  alone,  or  it  may 
be  a  mixed  infection.  Empyema  is  not  an  uncommon  sequela  of 
an  influenzal  pleurisy. 

Nervous. — .The  back  and  headache  and  joint  pains  mentioned  in 
connection  with  the  first  form  are  more  intense,  but  the  catarrhal 
symptoms  are  wanting.  Abscess  of  the  brain,  meningitis  or  mye- 
litis occur  sometimes  as  results  of  this  form  of  the  infection.  The 
bacillus  has  been  found  in  the  fluid  withdrawn  by  lumbar  puncture. 
Psychic  symptoms,  sometimes  amounting  to  insanity  are  important 
sequelas. 

Gastrointestinal. — The  onset  of  the  fever  is  with  nausea  and 
vomiting,  or  with  abdominal  pain,  profuse  diarrhea  and  collapse. 
There  may  be  jaundice,  enlargement  of  the  spleen  or  both.  This 
form  has  not  been  common  in  the  United  States  although  appendi- 
citis is  supposed  to  be  more  common  after  grippe  epidemics. 

Febrile. — It  is  important  to  recognize  the  fact  that  the  fever 
may  be  the  only  symptom  of  the  disease.  It  may  simulate  either 
malaria  or  typhoid,  and  blood  examinations  may  be  necessary  to 
clear  up  the  diagnosis. 

Complications. — There  may  be  pericarditis,  which  is  apt  to  be 
latent,  endocarditis,  or  myocarditis.  Functional  heart  troubles  as 
palpitation,  disturbances  of  rhythm,  cardiac  pain  and  the  like  are 


THE   DIPHTHERIA   GROUP.  Ill 

common.  Phlebitis  and  thrombosis  of  various  vessels  have  been 
observed. 

Septicemia  may  be  demonstrated  by  the  cultivation  of  the  bacillus 
from  the  circulating  blood.  Peritonitis  is  rare,  and  so  also  is  gall- 
stone formation,  though  both  have  been  observed. 

Acute  nviddle  ear  disease  is  perhaps  the  most  common  complica- 
tion and  has  as  its  sequete  inflammation  of  the  lahyrinth  with  its 
annoying  dizziness  and  mastoiditis  with  its  danger  to  life. 

Diagnosis. — During  an  epidemic  or  pandemic  this  offers  no  spe- 
cial difficulty.  In  sporadic  cases  of  the  respiratory  type,  the  sputum 
should  be  examined,  and  in  other  types  the  blood  cultivated  for  the 
bacillus.  The  striking  feature  which  differentiates  influenza  from 
all  else  is  the  prostration  which  is  so  out  of  proportion  to  the  in- 
tensity of  the  disease. 

Prophylaxis. — The  sick  should  be  isolated  whenever  practicable, 
and  the  aged  and  feeble  should  be  kept  so  far  as  possible  from 
possible  sources  of  infection.  This  is  made  difficult,  however,  by 
the  frequency  with  which  ' '  carriers ' '  are  found.  Should  the  disease 
gain  entrance  into  institutions,  the  sick  and  suspects  should  be  iso- 
lated as  soon  as  the  first  symptoms  are  seen. 

The  bodily  discharges,  especially  the  sputum,  should  be  disin- 
fected with  a  standard  disinfectant.  Fumigation  is  probably  not 
called  for,  since  the  disease  is  disseminated  almost  wholly  or  com- 
pletely by  carriers. 

The  rapidity  of  spread  of  epidemics,  in  which  almost  every  sus- 
ceptible person  in  the  community  will  be  attacked  within  6  or  8 
weeks,  makes  influenza  a  hard  disease  to  combat. 

Mortality. — Military  experience,  which  deals  entirely  with  se- 
lected lives,  shows  a  mortality  of  about  0.1  per  cent  while  civil 
statistics  give  a  mortality  of  0.5  per  cent.  "With  the  heavy  inci- 
dence of  the  disease,  this  rolls  up  a  formidable  mortality.  In  1904, 
in  the  registration  area  of  the  United  States  typhoid  fever  showed 
a  mortality  of  2,210,  while  for  the  same  time  and  area  influenza 
caused  2,752  deaths.  Of  these  2,752  deaths,  1,755  were  65  years  of 
age  and  over,  showing  the  great  influence  of  advanced  years  on  the 
danger  from  the  disease. 

Immunity. — Some  people  are  naturally  immune  to  influenza,  but 
an  attack  does  not  usually  confer  immunity,  though  perhaps  this 
•sometimes  occurs. 


112  PRACTICAI,   SANITATION. 

WHOOPING  COUGH. 

Definition. — A  specific  affection  characterized  by  catarrh  of  the 
respiratory  passages  and  a  series  of  convulsive  coughs  which  end 
in  a  long-drawn  inspiration  or  "whoop."     (Osier.) 

Etiology.— Sporadic  cases  appear  from  time  to  time  in  the  com- 
munity, becoming  epidemic  at  intervals.  It  is  probably  almost 
always  conveyed  by  droplet  infection,  though  it  is  said  to  be  carried 
at  times  by  fomites.  The  epidemics  appear  usually  during  the  win- 
ter and  last  into  the  spring,  a  period  of  2  or  3  months,  and  fre- 
quently precede  or  follow  those  of  scarlet  fever  or  measles.  It  is 
highly  infectious,  few  escaping  an  attack  at  some  time  during  life ; 
it  affects  by  preference  children  during  the  period  between  the  first 
and  second  dentitions,  and  girls  somewhat  more  frequently  than 
boys.  Often  severe  in  adults.  The  morbific  agent  is  supposed  to 
be  a  small  bacillus  with  rounded  ends  which  occurs  in  clumps  in 
the  sputum. 

Pathology. — No  special  pathology  is  found  in  this  disease,  but 
in  fatal  cases  the  picture  is  that  of  broncho-pneumonia. 

Immunity. — One  attack  usually  protects. 

Incubation. — 7  to  10  days. 

Symptoms. — Catarrhal  Stage. — The  symptoms  are  those  of  an 
ordinary  cold  with  slight  fever,  running  at  the  nose,  injection  of 
the  eyes  and  a  bronchial  cough,  generally  dry,  and  perhaps  some- 
what spasmodic. 

Paroxysmal  Stage. — This  dates  from  the  first  "whoop."  The 
paroxysm  begins  with  a  succession  of  short  expiratory  coughs,  15 
or  20  in  number,  compressing  the  chest  laterally  and  bulging  the 
sternum.  The  child  becomes  blue  in  the  face,  and  a  violent  inspira- 
tory effort  succeeds,  with  the  characteristic  whoop,  which  is  recog- 
nized instantly  even  by  the  laity.  Several  coughing  fits  may  follow 
in  rapid  succession,  with  ejection  of  bronchial  mucus  and  often 
vomiting.  The  vomiting  may  occur  so  frequently  that  the  child 
cannot  retain  sufficient  nourishment  and  becomes  greatly  emaciated. 
These  attacks  may  only  be  4  or  5  in  the  day,  or  in  severe  and  fatal 
cases  they  may  number  100.  Involuntary  urination  or  defecation 
may  occur.  Close  dusty  atmospheres  excite  the  paroxysms,  while 
clean  fresh  air  mitigates  them. 

The  course  of  the  disease  is  from  6  weeks  on  in  cases  of  ordinary 
severity,  gradually  declining  in  intensity  toward  the  end. 


THE   DIPHTHERIA    GROUP.  113 

Complications. — These  are  largely  due  to  the  terrific  strain 
thrown  on  the  circulation  during  the  preliminary  coughing. 
Hemorrhages  may  occur  into  the  skin,  conjunctiva,  brain  or  ab- 
dominal organs.     Death  may  occur  from  spasm  of  the  glottis. 

There  may  be  emphysema  or  rupture  of  the  lung,  or  bronchitis 
or  pneumonia.  Serious  damage  to  the  heart-valves  may  occur. 
Asthma  may  follow  and  persist  through  life.  {  ,/      - 

Prognosis. — AYhooping  cough  is  a  far  more  serious  disease  than 
is  generally  appreciated.  In  1903  there  were  9,522  deaths  in  Eng- 
land and  "Wales  from  this  disease,  97  per  cent  being  under  5  years 
of  age.  In  the  registration  area  of  the  United  States  for  the  years 
1900-1904,  the  total  number  of  deaths  was  17,978,  of  whom  8,083 
were  males  and  9,895  were  females.  95.5  per  cent  occurred  under  5 
years  and  more  than  half  under  1  year.  The  average  annual  death- 
rate  was  11.3  per  100,000.  This  is  much  lower  than  that  of  Euro- 
pean countries,  the  rate  in  Scotland  reaching  62  per  100,000  in 
1901. 

It  is  very  slightly  less  than  the  death-rate  for  scarlet  fever  in  the 
registration  area  for  the  same  time  (11.8)  but  almost  four  times 
that  of  smallpox  (3.7). 

Prophylaxis. — Children  and  non-inunune  adults  should  avoid 
public  gatherings  during  epidemics  of  whooping  cough.  Coughing 
children,  whether  whooping  or  not,  should  be  excluded  from  school 
and  Sunday  school.  Affected  children  should  be  quarantined  for 
at  least  5  weeks  from  the  beginning  of  the  disease  and  until  the 
whoop  has  entirely  ceased.  Immune  children  and  adults  need  not 
be  quarantined.  Isolation  has  little  value  after  the  disease  is  well 
started  in  the  community,  but  if  the  early  cases  can  be  properly 
handled,  the  epidemic  may  sometimes  be  stopped. 

Disinfection. — Not  generally  required,  but  formaldehyd  fumiga- 
tion will  do  no  harm,  particularly  in  the  earlier  cases. 

EPIDEMIC  PAROTITIS. 

Synonym. — Mumps. 

Definition. — A  specific  infectious  disease,  whose  cause  is  un- 
kno^^^l,  which  attacks  the  salivary  glands,  and  may  be  complicated 
by  other  glandular  inflammations,  particularly  of  the  testes. 

Etiology. — Endemic  in  large  cities,  becoming  epidemic  under 
circumstances  not  well  understood,  so  that  the  incidence  of  the 
disease   in   different   districts  of  the  same   city  is  very  unequal. 


114  PRACTICAL   SANITATION. 

Males  are  rather  more  frequently  attacked  than  females,  and  the 
disease  is  one  of  childhood  and  adolescence,  rarely  attacking  infants 
or  adults.  It  is  contagious  and  spreads  from  patient  to  patient, 
probably  by  droplet  infection. 

Incubation. — 2  to  3  weeks. 

Symptoms. — The  invasion  is  marked  by  fever,  usually  about  101° 
but  in  severe  cases  going  to  104°.  Pain  on  one  side,  just  below  the 
ear  is  complained  of,  and  a  slight  swelling  is  noticed  which  increases 
gradually  for  48  hours  until  there  is  present  great  swelling  of  the 
cheek  and  side  of  the  neck.  The  swelling  passes  forward  in  front 
of  the  ear,  lifting  the  lobe,  and  back  behind  the  sterno-mastoid 
muscle.  Both  glands  may  be  involved  in  turn,  and  the  submaxillary, 
sublingual  and  lachrymal  may  take  part  in  the  process.  The  pain 
is  seldom  severe  but  there  is  an  unpleasant  feeling  of  tension  in  the 
swollen  glands. 

The  swelling  of  the  salivary  glands  interferes  with  swallowing  to 
a  considerable  extent. 

There  may  be  earache,  sometimes  otitis  media,  and  slight  impair- 
ment of  hearing. 

Rarely  there  is  delirium,  with  high  fever  and  prostration,  passing 
even  into  a  typhoid  state. 

The  swelling  in  ordinary  cases  subsides  in  from  7  to  10  days,  the 
child  recovers  health  and  strength,  and  is  none  the  worse  for  the 
attack. 

Complications. — The  most  severe  is  orchitis,  which  rarely  attacks 
boys  before  puberty.  It  comes  on  usually  at  the  eighth  day  if  the 
boy  is  not  kept  in  bed.  One  or  both  testicles  may  be  involved. 
Earely  the  orchitis  precedes  the  parotitis.  In  some  cases  the  de- 
velopment of  the  testicle  is  checked  or  atrophy  ensues,  but  even 
when  both  are  involved,  sexual  vigor  may  be  retained,  though  the 
procreative  power  is  lost.  There  may  be  a  urethritis  also.  In  fe- 
males, the  breasts  are  attacked,  there  may  be  a  vulvo-vaginitis,  and 
rarely  the  ovaries  are  involved,  but  all  these  are  less  common  than 
the  orchitis  of  the  other  sex. 

The  disease  is  very  rarely  fatal. 

Prophylaxis. — Children  having  mumps  should  be  excluded  from 
school,  and  in  institutions  all  persons  attacked  should  be  promptly 
isolated.  The  disease  is  not  notifiable  or  quarantinable  and  but 
little  attention  is  given  to  its  prevention  outside  military  and  insti- 
tutional work. 


CHAPTER  IX 
THE  PLAGUE  GROUP. 

Diseases  of  this  group  are  properly  diseases  of  the  lower  animals, 
which  are  accidentally  comiunnicated  to  man.  This  may  be  by  an 
intermediate  host  as  in  plague,  by  direct  inoculation  as  in  hydro- 
phobia, by  ingestion  of  infected  material  as  in  Malta  fever  or  by 
infected  animals  or  their  skins  as  in  glanders  and  anthrax. 

Such  a  classification  is  not  altogether  satisfactory,  but  is  con- 
venient as  bringing  together  a  family  of  infections  which  does  not 
well  fit  in  elsewhere  and  also  as  emphasizing  the  fact  that  man 
must  exercise  supervision  over  his  animal  neighbors  if  he  expects 
to  remain  free  from  their  diseases. 

PLAGUE. 

Synonyms. — Bubonic  Plague;  Oriental  Plague;  Black  Death; 
Black  Plague ;  Pestis  Hominis. 

Definition. — The  Plague  is  a  febrile  infectious  disease,  character- 
ized by  a  tendency  to  buboes  or  carbuncles,  in  addition  to  the  usual 
phenomena  of  the  typhoid  state  (Tyson). 

Habitat. — Bubonic  plague  is  properly  a  disease  of  the  Orient, 
whence  it  has  spread  at  irregular  and  long  intervals  in  epidemics 
and  pandemics.  It  is  at  present  apparently  endemic  in  India  and 
China,  having  resisted  for  15  years  strenuous  efforts  on  the  part  of 
the  Indian  authorities  to  eradicate  it. 

Etiology. — Plague  is  a  disease  primarily  of  the  Siberian  marmot, 
or  tardagan,  an  animal  allied  to  our  prairie  dog  and  woodchuck. 
This  animal  is  the  only  one  now  known  to  have  the  disease  in  chronic 
form,  all  other  animals  either  perishing  promptly  or  recovering  in 
a  comparatively  short  time.  This  marmot  furnishes  a  carrier  which 
is  capable  of  maintaining  a  supply  of  the  germ  for  an  indefinite 
time.  Plague  is  also  a  disease  of  other  rodents  as  the  rats  and 
squirrels.  On  this  account  all  antiplague  measures  have  as  their 
foundation  the  destruction  of  rodents.  For  this  reason  the  United 
States  Government  and  the  State  of  California  have  spen.t  much 

115 


ll(j  •  PRACTICAL   SANITATION. 

time  and  money  in  the  destruction  of  ground-sqviirrels  around  San 
Francisco  Bay  and  in  other  localities.  There  is  reason  to  believe 
that  if  the  disease  should  spread  among  the  rats  and  gophers  of 
the  Sierras,  it  might  in  time  reach  the  territory  inhabited  by  the 
prairie  dog  and  there  become  endemic,  as  it  is  among  the  tarhagans 
of  IManchuria  and  eastern  Siberia. 

Bacteriolog'y. — The  bacillus  of  plague  (B.  pestis)  is  a  short  rod 
with  rounded  ends,  resembling  the  bacillus  of  chicken  cholera.  It 
is  found  in  the  blood  and  glands  and  can  be  cultivated  with  little 
difficulty.  It  obtains  entrance  to  the  body  by  the  respiratory  and 
digestive  tracts,  but  particularly  through  the  bite  of  the  rat-flea, 
which  leaves  the  body  cf  the  dead  or  dying  rat  and  takes  refuge 
wherever  it  can.  The  bacillus  is  also  found  in  virulent  form  in 
the  dust  of  infected  houses,  in  this  resembling  anthrax  and  tet- 
anus. 

Pathology. — There  is  no  special  morbid  anatomy  to  the  disease, 
beyond  the  buboes  and  internal  suppurations,  subcutaneous  and 
other  hemorrhages,  and  the  general  picture  of  the  effects  of  high 
fever.  The  liver  and  kidneys  are  congested  and  the  spleen  enlarged 
to  several  times  its  normal  size. 

Varieties. — There  are  four  distinct  types  of  this  infection :  pestis 
minor,  the  abortive  or  larval  form,  which  is  the  usual  precursor  of 
epidemics,  and  is  the  form  which  is  endemic  in  certain  localities. 
There  is  little  fever,  the  lymphatics  are  little  swollen,  there  is  not 
much  constitutional  disturbance,  and  the  disease  usually  terminates 
favorably  in  about  2  weeks;  the  huhonic  form,  which  is  the  more 
common  severe  epidemic  type,  in  which  there  is  great  lymphatic 
enlargement  and  which  constitutes  about  70  per  cent  of  all  cases 
of  plague;  the  septicemic  type,  sometimes  called  toxic,  siderant  or 
fulminant,  in  which  death  takes  place  too  soon  for  any  marked 
anatomical  changes  to  develop,  often  within  24  hours;  the  pneu- 
m,onic  form,  in  which  the  force  of  the  disease  is  spent  on  the  lungs 
and  the  sputum  is  charged  with  the  bacilli. 

Incubation. — 2  to  7  days. 

Symptoms. — Bubonic  or  Ordinary  Type. — After  the  period  of 
incubation,  the  first  symptom  is  ordinarily  a  most  intense  weak- 
ness. This  may  be  followed  by  headache,  nausea,  vomiting,  vertigo 
and  rarely  lumbar  pain.  There  is  usually  no  chill  but  a  feeling 
of  chilliness  may  be  present.  The  fever  sets  in  rapidly,  going  up 
at  once  to  102°  to  104°  or  higher.     The  pulse  is  from  90  to  120, 


THE   PLAGUE    GROUP,  117 

often  dicrotic.  Petecliiae  and  vibices  are  seen,  and  hemorrhages 
from  the  kidneys  and  stomach  are  not  uncommon.  Albuminuria 
is  the  rule.  The  spleen  is  slightly  enlarged.  On  the  second  or 
third  day,  if  the  patient  has  not  succumbed,  the  huhoes  appear  in 
any  or  all  of  the  regions  having  lymphatic  nodes  close  to  the  sur- 
face. These  buboes  come  up  rapidly,  and  on  reaching  the  size  of 
an  egg  or  a  little  less,  rupture  unless  sooner  opened,  as  a  rule. 
More  rarely  they  undergo  resolution  without  suppuration.  The 
buboes  are  tender  and  painful,  but  the  occurrence  of  suppuration 
is  a  favorable  sign.  Coincident  with  it,  a  profuse  sweat  comes  out 
and  the  temperature  drops,  the  pulse  also  subsiding.  Carbuncles 
on  any  part  of  the  body  are  a  distressing  concomitant  of  this  form 
of  the  disease. 

Pneumonic  Type. — Here  are  seen  the  usual  symptoms  of  a  pneu- 
monia, but  instead  of  the  pneumococcus,  the  plague  bacillus  is  found 
in  the  sputum. 

Septicemic  Type. — In  this  form  the  toxins  overwhelm  the  body 
too  rapidly  for  reaction  to  take  place,  hence  the  symptoms  are  few. 
There  is  the  most  intense  prostration,  sometimes  without  fever. 
The  lymphatics  and  spleen  are  enlarged  everywhere,  but  only  to  a 
small  degree.  Hemorrhages  from  nose,  bowel,  .or  kidneys  are  very 
characteristic  of  this  form.     There  is  typhoid  delirium. 

Diagnosis. — This  disease  is  not  likely  to  be  mistaken  for  anything 
except  typhus,  and  is  differentiated  from  that  by  the  very  great 
pain  accompanying  the  latter  disease.  The  isolation  of  the  Bacillus 
pestis  from  sputum,  blood  or  pus  will  settle  the  diagnosis.  An  epi- 
zootic in  wtiich  rats  are  found  dead  in  the  streets  will  at  once  put 
the  sanitarian  on  his  guard  against  plague. 

Prognosis. — Plague  is  the  most  fatal  of  epidemic  diseases,  from 
70  to  90  per  cent  perishing. 

Individual  Prophylaxis. — By  vaccination  with  the  dead  bacilli, 
after  Haffkine's  method,  which  is  comparable  to  the  other  bacterial 
inoculations.  A  mask  should  be  worn  when  near  pneumonic  cases 
to  prevent  droplet  infection.  Suppurating  cases  and  in  fact  all 
others  should  be  handled  with  rubber  gloves  to  prevent  direct  skin 
inoculation  through  abrasions. 

Sera. — Lustig  and  Yersin  have  prepared  curative  sera  by  some- 
what different  methods,  which  are  comparable  to  the  diphtheria 
antitoxin.  In  case  persons  have  been  exposed  to  the  plague,  a  dose 
of  one  of  these  sera  should  be  administered  before  the  Haffkine 


118  PRACTICAL   SANITATION. 

vaccine  is  administered,  in  order  to  prevent  the  development  of  a 
possible  phase  of  increased  susceptibility  which  is  sometimes  known 
to  occur. 

Community  Prophylaxis. — As  before  stated,  this  depends  on  the 
prompt  and  complete  destruction  of  rats,  and  their  barring  out  from 
gaining  re-entrance  to  buildings  of  all  kinds.  These  methods  are 
eonipletely  covered  in  Chapter  XXIX,  page  270.  The  health  of- 
ficer who  suspects  that  plague  has  made  an  appearance  among  the 
rats  in  his  territory  should  at  once  communicate  with  his  State 
Board,  who  will  send  a  laboratory  worker  to  aid  in  making  a  diag- 
nosis. If  this  is  confirmed,  at  the  request  of  the  State  Board  the 
Public  Health  Service  will  at  once  send  experts  to  take  charge 
of  the  situation  who  will  be  provided  Math  antipest  serum  and 
vaccines,  which  are  not  usually  obtainable  commercially.  Unless 
the  disease  is  diagnosed  from  rats,  there  will  probably  be  a 
number  of  human  cases  of  pestis  minor  and  the  disease  fairly  well 
established  before  the  occurrence  of  a  bubonic  case  gives  the  clue 
to  the  diagnosis.  Plague  should  be  taken  care  of  in  special  isolation 
hospitals  (see  Chapter  IV). 

Quarantine. — The  Regulations  of  the  Public  Health  Service 
specify  7  days  as  the  period  of  quarantine  for  contacts.  For 
pneumonic  or  bubonic  eases  recovering  the  British  regulations  re- 
quire 1  month's  isolation.  If  the  plague  bacilli  are  still  recover- 
able from  any  secretion,  the  patient  should  not  be  discharged, 
and  if  repeated  examination  shows  him  free  he  may  be  safely  dis- 
charged without  regard  to  time. 

Disinfection. — This  consists  of  two  parts:  Disinfection  against 
the  bacilli,  which  is  necessary  since  it  has  been  shown  that  they 
are  able  to  live  even  in  the  dry  state  for  a  period  of  4  months  if 
the  place  is  dark  and  the  temperature  does  not  rise  above  68°,  and 
disinfection  aimed  against  the  flea  and  his  rodent  host.  Formalde- 
hyd  is  efficient  against  the  former,  but  does  not  kill  the  latter  two. 
Sulphur  used  according  to  the  directions  on  page  58  kills  all 
three.  If  formaldehyd  is  used  it  must  be  supplemented  by  hydro- 
cyanic acid,  camphor  (see  page  59),  or  the  oxides  of  carbon. 
Either  sulphur  or  the  formaldehyd-hydrocyanic  acid  combination  is 
well  followed  by  bichloride,  cresol  or  carbolic  spray,  since  all  fomites 
may  not  have  been  reached  by  the  fumigation,  and  in  the  presence 
of  albuminous  material  the  bacillus  may  continue  virulent  for  a 
long  time. 


THE   PLAGUE    GROUP.  119 

MALTA  FEVER. 

Synonyms. — Mediterranean  Fever;  Neapolitan  Fever;  Rock 
Fever;  Undiilant  Fever. 

Definition. — An  irre^lar  fever,  characterized  by  alternate  re- 
missions and  relapses,  sweats  and  rheumatoid  pains,  caused  by  the 
Micrococcus  melitensis. 

Distribution. — Mediterranean  Countries ;  Eastern  Asia ;  sporadic 
in  "West  Indies;  Mexico  and  Texas. 

Etiology. — It  is  primarily  a  disease  of  goats,  and  is  conveyed  by 
the  milk  of  the  animal,  and  possibly  by  biting  insects.  The  organism 
is  found  in  large  numbers  in  the  spleen,  but  not  as  yet  in  the  gen- 
eral circulation.  In  the  human  race  the  method  of  infection  from 
person  to  person  and  the  degree  of  infectiousness  are  not  yet 
settled. 

Pathology. — The  gross  lesions  are  those  of  typhoid. 

Predisposing  Factor. — ^Youth. 

Incubation. — 6  to  10  days. 

Symptoms.- — Onset  gradual;  headache,  sleeplessness,  thirst;  loss 
of  appetite,  no  chilliness  or  high  fever  at  first. 

No  diarrhea  or  rose  spots.  These  symptoms  continue  for  3  to  4 
weeks,  mth  a  following  remission,  simulating  convalescence.  After 
a  few  days  of  remission  the  second  attack  occurs,  with  rigors,  high 
fever  and  frequently  diarrhea.  This  relapse  continues  for  5  or  6 
weeks,  followed  by  a  second  remission  of  10  to  14  days,  and  a  second 
relapse  wliich  has  the  same  symptoms  as  the  preceding,  with  the 
addition  of  great  debility,  night  sweats,  pain  in  the  joints  and 
testicles,  lasting  3  or  4  weeks.  This  is  followed  by  a  third  remis- 
sion lasting  a  month  or  6  weeks. 

There  is  then  a  third  relapse,  shorter  in  duration  adding  to  the 
previous  symptoms  a  heavily  coated  tongue,  a  normal  morning 
temperature  mth  high  evening  rise  (105°)  with  very  severe  night 
sweats  and  rheumatic  pains.  Motion  is  difficult  owing  to  pain  in 
the  joints. 

Diagnosis. — Difficult  on  account  of  the  rarity  of  the  disease,  but 
may  be  made  by  the  reaction  of  the  serum  on  suspensions  of  the 
Micrococcus  melitensis. 

Prognosis. — Favorable ;  about  2  per  cent  dying. 

Prophylaxis. — Avoid  milk  of  goats  imported  from  Mediterranean 
countries  or  from  the  endemic  center  in  Texas.     The  dust  contain- 


120  PRACTICAL   SANITATION. 

ing  the  droppings  of  these  goats  is  infectious  even  after  19  days' 
drying,  so  that  the  vicinity  of  infected  flocks  must  also  be  avoided. 

If  in  summer  keep  patient  under  mosquito  bar  or  in  well-screened 
room. 

Quarantine. — None. 

Disinfection. — None. 

ANTHRAX. 

Synonyms. — Malignant  Pustule;  Contagious  Carbuncle;  Splenic 
Fever;  Splenic  Apoplexy;  Gangrene  of  the  Spleen;  Carbuncle 
Fever;  Blood-striking;  Choking  Quinzy;  Bloody  Murrain;  Wool- 
sorters'  Disease;  Rag-sorters'  Disease;  Charbon  (Fr.)  ;  Milzbrand 
(Ger.). 

Definition. — An  acute  infectious  disease  of  animals,  particularly 
affecting  cattle  and  sheep,  but  transmissible  to  man,  caused  by  the 
implantation  and  multiplication  of  the  Bacillus  anthracis  (Tyson). 

Etiology. — The  bacillus  of  anthrax  is  the  largest  of  the  patho- 
genic bacilli,  being  from  5  to  20  mi.  in  length,  and  1  to  1.25  mi.  in 
thickness.  It  is  spore-bearing  and  aerobic,  and  can  be  isolated  in 
enormous  numbers  from  the  tissues  of  infected  animals.  The  spores 
may  retain  their  vitality  even  under  unfavorable  conditions  for 
long  periods  of  time,  even  for  years,  their  virulence  remaining  un- 
affected. Those  most  frequently  affected  are  herdsmen,  stable- 
hands,  butchers,  slrinners  of  dead  animals  and  wool-sorters. 

Pathology. — The  body  after  death  is  cyanotic,  blood  dark  and 
stringy,  coagulating  slowly,  and  the  spleen  soft  and  enlarged.  The 
gastrointestinal  membrane  is  swollen  and  ecchymotic;  gangrenous 
patches  are  seen,  and  blood  escaping  from  the  vessels  appears  here 
and  there  under  the  skin.  Plugs  of  bacilli  are  found  in  the  blood- 
vessels. 

Incubation. — About  7  days. 

Symptoms. — External  Anthrax. 

(1)  Malignant  Pustule. — This  appears  most  frequently  on  ex- 
posed parts  of  the  body  as  the  face,  hands  and  arms,  wherever  the 
inoculation  has  taken  place.  It  begins  with  itching,  which  is  inten- 
sified to  a  sharp  burning  pain,  like  the  bite  of  an  insect.  Redness 
follows,  developing  rapidly  into  a  papule,  in  the  center  of  which 
a  vesicle  appears,  filled  with  fluid  which  may  be  clear  or  cloudy. 
The  vesicle  bursts  and  the  papule  enlarges  and  becomes  indurated. 
A  number  of  daughter  vesicles  then  form.     The  induration  extends 


THE   PLAGUE   GROUP.  121 

and  becomes  brownish  at  the  center  which  forms  an  eschar  in  about 
36  hours;  this  soon  sloughs  and  disintegrates,  the  vicinity  of  the 
pustule  becomes  edematous,  the  lymphatics  take  up  the  infection 
and  become  hard,  swollen  and  painful.  The  general  symptoms  are 
those  of  a  violent  infection,  with  thirst,  high  temperature  and  rapid 
pulse.  The  liver  enlarges  and  the  spleen  becomes  large,  dark  and 
very  friable. 

Death  ensues  in  almost  all  cases  in  from  2  to  5  days.  Only  in 
the  mildest  cases  does  the  scab  dry  up  and  the  symptoms  subside. 

(2)  Malignant  Anthrax  Edema. — This  begins  in  the  eyelids  and 
spreads  to  the  head,  face  and  arms.  The  skin  is  reddened,  and 
vesicles  and  gangrene  may  appear,  but  there  are  no  papules.  The 
constitutional  symptoms  appear  before  the  local,  and  this  form  of 
anthrax  is  even  more  deadly  than  the  preceding. 

Internal  Anthrax. — ^(1)  Intestinal  Anthrax. — The  infection 
is  by  the  alimentary  tract ;  the  early  symptoms  are  chill,  vomiting, 
bloody  diarrhea,  abdominal  pain  and  tenderness.  The  conditions 
mentioned  in  a  preceding  paragraph  are  found  in  the  gastrointes- 
tinal canal  at  autopsy.  Pustules  may  form  on  the  skin.  It  is  in- 
variably fatal. 

(2)  Wool-sorters'  Disease  {Pulmonary  Anthrax). — This  arises 
from  the  inhalation  of  the  bacilli  in  dust  arising  from  infected 
wool,  hides,  or  rags.  The  symptoms  are  like  those  of  the  preceding 
form  except  that  the  intestinal  symptoms  are  replaced  by  pulmonary 
symptoms,  as  cough  and  bronchitis,  with  the  physical  signs  of 
pulmonary  involvement.  Premonitory  symptoms  are  usually  want- 
ing and  external  lesions  not  discernible.  It  is  rapidly  fatal,  usually 
in  24  hours.  After  death  the  capillaries  of  the  lungs  and  brain 
may  be  found  choked  with  bacilli.  The  prognosis  is  bad,  but  if 
the  patient  is  able  to  survive  one  week  he  may  ultimately  recover. 

Diagnosis. — In  external  anthrax  this  is  easily  done  by  staining 
a  little  of  the  fluid  from  a  pustule  and  examining  for  the  bacilli, 
which  are  very  large  and  easily  recognized.  A  mouse  or  guinea-pig 
may  be  inoculated  and  the  bacilli  recovered  from  the  internal 
organs.  Internal  anthrax  is  apt  to  go  unrecognized  unless  exami- 
nation is  made  of  feces  or  sputum  in  the  appropriate  type  of  infec- 
tion, and  inoculation  experiments  carried  out.  A  symptom  complex 
like  the  ones  above  noted  in  men  whose  occupation  brings  them 
into  contact  with  herbivorous  animals  or  with  wool  should  arouse 
suspicion  and  suggest  the  use  of  the  microscope. 


122  PRACTICAL   SANITATION. 

Prophylaxis. — Animals  dead  of  this  disease  sliould  be  cremated 
and  no  attempt  made  to  utilize  any  part  of  the  carcass.  Wool  and 
rags  should  be  sterilized  by  super-heated  steam  and  hides  thrown 
into  vats  containing  formaldehyd  solution  with  at  least  1  per  cent 
of  formaldehyd  gas,  and  allowed  to  remain  for  12  to  24  hours 
before  removal. 

Quarantine. — Absolute,  till  the  death  or  recovery  of  the  patient. 
Only  nurse,  physician  and  undertaker  should  be  allowed  to  come 
in  contact  with  the  patient,  and  they  should  protect  themselves 
most  carefully  by  the  use  of  rubber  gloves,  while  physician  and 
nurse  should  wear  a  face  mask  to  protect  against  "droplet  infec- 
tion." 

Disinfection. — With  a  double  quantity  of  formaldehyd  for  12 
hours  with  proper  moisture.  Infection  from  one  person  to  another 
is  not  common,  simply  because  the  disease  is  not  common,  and  it 
must  be  borne  in  mind  that  this  disease  is  one  of  three  or  four 
absolutely  known  to  be  transmissible  by  fomites. 

Prevalence. — The  largest  number  of  deaths  in  the  registration 
area  reported  in  the  last  10  years  is  25  in  1904. 

GLANDERS  AND  FARCY. 

Synonym. — Malleus  humidus. 

Definition.— An  infectious  disease  more  particularly  of  the  horse, 
but  communicable  to  man  and  other  mammalia.  It  is  characterized 
by  nodular  growths  in  the  nose  (glanders)  or  under  the  skin 
(farcy). 

Etiology. — This  disease  is  due  to  infection  with  the  Bacillus 
mallei,  which  is  a  short  non-motile  bacillus,  not  unlike  that  of 
tuberculosis  and  leprosy  in  shape,  but  shorter.  It  is  most  usually 
found  in  the  characteristic  lesions,  but  is  also  to  be  cultivated  from 
the  blood. 

The  disease  is  communicated  through  abrasions  on  the  skin  or  by 
inoculation  on  the  intact  mucous  membrane.  This  is  an  occupa- 
tional disease  of  hostlers  and  others  having  to  work  with  horses. 

Pathology. — The  characteristic  lesions  are  the  nodules  and 
"l)uds"'  which  vary  from  lentil-  to  fist-size,  and  are  composed  of 
round  cells  invading  the  tissues,  which  tend  to  break  down  and 
form  ulcers,  often  with  underlying  abscesses,  especially  under  the 
skin.     Any  of  the  tissues  of  the  body  may  be  involved  in  the  process. 


THE   PLAGUE    GROUP. 


123 


Incubation. — 3  to  5  days,  rarely  1  week. 

Symptoms.— Acute  Forms. — Glanders.— Uedness  and  swelling  of 
the  nasal  mucous  membrane  at  the  point  of  inoculation,  with  dry- 
ness and  burning  in  surrounding  portions  of  the  nasal  tract.  In- 
tense pain  from  frontal  sinus  involvement  may  be  present.  This 
is  quickly  followed  by  nodule-formation  with  rapid  breaking-down 
of  the  same,  and  ulceration,  with  the  discharge  of  foul-smelling 
pus.  The  process  extends  to  the  remainder  of  the  nose,  accessory 
sinuses,  pharynx,  larynx,  and  lungs,  and  to  other  organs.  The 
submaxillary  glands  swell  and  suppurate.  Painful  swallowing, 
hoarseness,  and  cough  are  the  symptoms  dependent  on  these  lesions. 

Farcy. — The  typical  swellings  appear  in  the  skin,  which  become 
nodular  and  ulcerate,  discharging  a  fetid  blood-stained  pus. 
Papules  which  become  pustular  may  develop  in  the  neighborhood. 
The  eruption  has  been  mistaken  for  smallpox  in  cases  where  the 
latter  lesions  predominate.  "Farcy  buds"  form  along  the  lym- 
phatics, and  are  nodular  enlargements  under  the  skin.  The  nose 
is  not  involved. 

The  symptoms  common  to  both  the  acute  forms  are  chilliness, 
high  temperature,  intense  prostration,  pain  and  soreness  in  mus- 
cles and  joints,  abscess  formation,  the  typhoid  state,  and  death. 

Chronic  Forms. — Glanders. — The  symptoms  are  those  of  an  in- 
curable coryza  or  laryngitis.     It  is  not  easy  to  recognize. 

Farcy. — The  nodules  break  down,  but  the  lymphatics  are  not 
involved,  and  the  process  is  slow.  Acute  glanders  or  farcy  may 
supervene  on  the  chronic  form.  The  constitutional  symptoms  are 
not  so  severe  or  are  wanting  in  both  chronic  types. 

Diagnosis. — By  mallein,  an  aqueous  extract  of  the  B.  mallei, 
which  is  used  in  the  same  manner  as  tuberculin,  and  by  the  aggluti- 
nation test,  the  serum  being  diluted  to  200  or  more.  The  disease 
has  exceptionally  been  mistaken  for  smallpox  or  pyemia,  but  the 
two  tests  above  noted  or  the  recognition  of  the  bacilli  in  wound- 
secretions  or  cultures  will  differentiate  from  these  conditions  at 
once. 

Glanders  Pneumonia  is  sometimes  seen,  the  lung  appearing  like 
an  ordinary  caseous  pneumonia. 

Albuminuria  may  be  present  and  the  liver  and  spleen  enlarged 
in  any  form  of  the  disease. 

Prognosis. — Acute  glanders  is  invariably  fatal.     Acute  farcy  is 


124  PRACTICAL   SANITATION. 

usually  fatal  in  from  12  to  15  days.  About  50  per  cent  of  the 
chronic  cases  recover. 

Prophylaxis. — Animals  suspected  of  having  the  disease  should 
be  handled  with  the  utmost  care,  and  as  soon  as  a  positive  diagnosis 
is  made  should  be  killed  and  the  bodies  burned.  It  is  communicable 
from  man  to  man,  and  by  fomites.  Washerwomen  have  been  in- 
fected by  the  soiled  linen  of  persons  sick  with  the  disease. 

Quarantine. — The  quarantine  and  disinfection  are  as  for  anthrax. 

Prevalence. — Not  more  than  8  deaths  have  occurred  in  the  regis- 
tration area  in  any  one  year  of  the  last  decade. 

FOOT-AND-MOUTH  DISEASE. 

Definition. — An  infectious  disease  of  the  lower  animals,  com- 
municable to  man.  Cattle,  sheep. and  hogs  are  most  commonly  in- 
fected, horses  and  goats  less  often,  and  fowls,  dogs  and  cats  still 
more  rarely  (Tyson). 

It  is  characterized  in  these  animals  by  fever,  and  the  presence 
of  vesicles  and  ulcers  in  the  mucous  membrane  of  the  mouth,  in 
the  furrows  and  clefts  about  the  feet,  and  about  the  teats  of  animals. 

Etiology. — The  specific  organism  is  not  known,  though  a  strep- 
tococcus and  a  micrococcus  have  been  described.  The  disease  is 
chiefly  communicated  by  the  contents  of  the  vesicles  alluded  to, 
but  the  urine,  feces,  saliva,  as  well  as  unboiled  milk,  butter  and 
cheese  may  convey  the  contagion.  The  virus  is  filterable  through 
a  Pasteur-Chamberland  porcelain  filter. 

Incubation. — 3  to  5  days. 

Symptoms. — Fever,  malaise,  loss  of  appetite ;  the  vesicles  appear 
in  the  mouth,  chiefly  on  the  lips  and  tongue,  but  sometimes  on  the 
pharynx  and  hard  palate,  and  exude  a  yellowish  serum;  simul- 
taneously or  a  trifle  later  they  come  out  around  the  nails,  between 
the  fingers  and  toes,  and  more  rarely  around  the  nipples  of  women, 
or  over  the  whole  body,  like  smallpox. 

Prognosis. — Favorable  in  all  cases  except  very  young  children 
who  sometimes  die. 

Prophylaxis. — ]\Iilk  from  herds  suffering  with  this  disease  must 
be  excluded  from  the  market  until  the  epizootic  is  over.  Boiled 
milk  is  safe.  The  widespread  epizootic  of  1914—15  showed  very 
few  human  cases  and  no  deaths.  Simple  measures  of  cleanliness 
are  sufficient  to  prevent  the  infection  of  the  human  subject,  who  is 
relative! \'  innnune. 


THE   PLAGUE    GROUP. 


125 


Quarantine  and  disinfection  are  not  required,  but  are  probably 
advisable. 

HYDROPHOBIA. 

Synonyms. — Rabies;  Lyssa. 

Definition. — Hydrophobia  is  an  acute  infectious  disease,  of  vari- 
able but  usually  long  period  of  incubation,  characterized  by  tonic 
spasms,  beginning  in  the  larynx. 

Etiology. — The  disease  is  common  to  all  warm-blooded  animals, 
and  is  communicable  only  by  inoculation,  usually  by  biting.  The 
dog  is  the  animal  most  commonly  affected  and  the  agent  by  which 
the  disease  is  most  commonly  communicated  to  man.  The  virus  is 
contained  in  the  saliva,  and  in  all  the  nervous  tissues.  The  poison 
reaches  the  saliva  by  way  of  the  nerves  and  not  through  the  blood 
vessels.  Its  intensity  varies  with  the  species  of  the  biting  animal; 
wolves,  cats,  dogs,  and  other  animals  forming  in  this  order  a  de- 
scending scale  of  virulence.  It  varies  further  with  the  age  of  the 
patient,  younger  children  not  only  being  more  frequently  attacked, 
but  more  susceptible ;  with  the  location  of  the  bite,  wounds  on  the 
face  and  head  or  in  parts  richly  supplied  with  nerves  being  more 
dangerous;  with  the  extent  of  laceration,  large  wounds  carrying 
more  of  the  infecting  virus  and  being  more  difficult  to  clean  and 
cauterize  thoroughly,  the  punctured  wounds  caused  by  the  canine 
teeth  of  dogs  and  wolves  being  particularly  grave.  Only  about  15 
per  cent  of  those  bitten  by  dogs  contract  the  disease,  while  wolf- 
bites  give  a  mortality  of  60  to  80  per  cent. 

Incubation. — The  average  period  is  from  6  weeks  to  2  months, 
but  in  a  few  cases  has  been  less  than  2  weeks. 

Pathology. — The  essential  feature  of  the  pathology  of  hydro- 
phobia is  the  presence  in  the  central  nervous  system  of  irregular 
bodies  called  "Negri  Bodies"  from  4  to  10  mi.  in  size,  which  are 
probably  protozoa,  but  as  yet  of  unsettled  classification. 

Symptoms. — Premonitory  Stage. — There  may  be  irritation  or 
numbness  about  the  bite;  depression  or  melancholy;  headache, 
irritability  and  loss  of  appetite.  Bright  lights  or  loud  noises  are 
distressing.  The  larynx  is  often  congested  and  the  voice  husky, 
while  the  first  symptoms  of  difficulty  in  swallowing  soon  appear. 
The  temperature  is  slightly  raised  and  the  pulse  accelerated. 

Stage  of  Excitement. — This  is  characterized  by  great  excita- 
bility, restlessness  and  extreme  hyperesthesia,  so  that  the  slightest 


126  PRACTICAL   SANITATION. 

stimulus  such  as  from  a  draught  of  air  or  a  light  touch  is  sufftcient 
to  bring  on  a  convulsion.  This  is  the  most  distressing  feature  of 
the  malady  to  witness.  There  are  exceedingly  painful  spasms  of 
the  muscles  of  the  larynx  and  mouth,  accompanied  by  a  frightful 
sense  of  dyspnea,  even  after  tracheotomy.  Any  attempt  to  swallow 
brings  on  spasm  of  the  muscles  involved,  a  fact  which  has  given 
the  name  liydrophohia  to  the  disease.  There  may  be  maniacal 
symptoms.  In  the  intervals  the  patient  may  be  quiescent  and  ra- 
tional. The  temperature  is  from  100°  to  103°.  The  patient  rarely 
attempts  to  hurt  anyone,  and  even  in  the  most  severe  spasms  may 
be  most  careful  to  avoid  it.  The  spasmodic  contractions  of  the 
laryngeal  muscles  may  give  rise  to  odd  sounds  like  the  voice  of  the 
lower  animals,  which  has  given  origin  to  the  superstition  that  hydro- 
phobic patients  bark  like  dogs.  This  stage  lasts  from  1  to  3  days 
and  passes  into  the  paralytic  stage. 

The  Paralytic  Stage. — The  patient  becomes  quiet,  the  spasms 
no  longer  torment,  the  heart  weakens,  and  death  occurs  by  syncope 
in  from  6  to  18  hours  after  the  supervention  of  this  stage. 

Diagnosis. — The  diagnosis  usually  offers  no  difficulty.  The 
symptoms  taken  with  the  history  of  a  bite  by  a  dog  or  other  animal 
some  time  before  make  the  matter  only  too  plain.  The  only  diag- 
nosis which  is  of  value  is  to  be  made  from  the  brain  of  the  biting 
animal,  or  by  observation  of  the  living  animal  for  at  least  10  days. 
If  at  the  end  of  this  time  it  is  in  good  health,  hydrophobia  is  not 
to  be  feared.  The  methods  for  sending  the  brain  to  the  laboratory 
are  fully  described  in  Part  III,  page  382. 

Prophylaxis. — The  prophylaxis  of  hydrophobia  is  to  be  obtained 
by  the  systematic,  long-continued  muzzling  of  all  dogs.  In  Ameri- 
can communities  the  comfort  of  the  dog  is  usually  rated  higher  than 
human  life  and  the  measure  is  applied  only  half-heartedly  and  is 
valueless.  The  only  proper  muzzle  is  one  of  wire,  which  allows  the 
dog  to  open  his  mouth  but  prevents  him  from  biting.  Straps  around 
the  jaw  do  not  prevent  him  from  biting  and  make  him  very  uncom- 
fortable. 

Bites  of  rabid  animals  are  best  cauterized  with  the  actual  cautery, 
with  nitric  acid  or  pure  carbolic  acid,  followed  by  alcohol. 

Preventive  Inoculation  which  was  originated  by  Pasteur,  con- 
sists of  intensifying  the  action  of  the  virus  by  passing  it  through 
successive  rabbits,  until  the  period  of  incubation  is  reduced  to  7 
days.     The  spinal  cords  of  these  rabbits  are  preserved  in  dry  air 


THE   PLAGUE   GROUP.  127 

for  12  to  15  days,  and  a  small  quantity  of  the  emulsion  prepared 
by  triturating  the  cord  with  physiological  salt  solution  is  injected 
into  the  person  to  be  immunized.  Tliis  is  followed  by  injections 
on  the  follo^ving-  days  of  emulsions  made  from  cords  which  have 
been  preserved  for  fewer  and  fewer  days,  the  contained  virus  being 
stronger  and  stronger.  This  method  has  given  the  most  gratifying 
results,  and  where  it  is  undertaken  promptly  is  rarely  unsuccessful. 
This  virus  is  now  supplied  by  several  biological  product  houses,  so 
that  the  treatment  is  capable  of  administration  by  any  well-quali- 
fied physician;  several  states  also  supply  it  or  administer  it  free 
of  charge  to  the  poor. 

Prognosis. — In  developed  eases,  absolutely  fatal.^ 
Prevalence. — The  registration  area  of  the  United  States  shows 
for  the  period  1901-5  an  average  of  42  deaths  from  hydrophobia; 
1903,  43;  1904,  38;  1905,  44;  1906,  85;  1907,  75;  1908,  82.  In 
view  of  the  frightful  physical  and  mental  suffering  involved,  and 
the  certainty  of  death  at  the  end,  it  would  seem  that  no  measures 
are  too  drastic  to  prevent  the  spread  of  this  disease. 


^  October,  1913.  Treatment  based  on  the  supposed  protozoal  nature  of  the  Negri 
bodies  bv  large  doses  of  quinine  administered  hjpodermically  is  reported  to  have  re- 
sulted successfully.  In  view  of  the  hopeless  prognosis  it  is  worth  trying.  Any  soluble 
salt  of  quinine  may  be  used. 


CHAPTER  X 

THE  YELLOW  FEVER  GROUP. 

The  diseases  of  this  group  are  alike  in  having  a  known  or  prob- 
able protozoon  origin,  having  two  cycles — an  endoeorporeal  or 
human  cycle,  which  is  characterized  by  the  asexual  multiplication 
of  the  parasite,  and  an  extracorporeal  or  sexual  cycle  within  the 
body  of  some  winged  insect,  which  sexual  cycle  requires  a  period  of 
some  days  before  the  insect  becomes  capable  of  reinfecting  the 
human  body. 

Besides  the  diseases  here  mentioned,  two  others  at  least  should 
be  noted  which  are  omitted  for  reasons  of  space :  African  sleeping 
sickness,  Mdiich  is  a  trypanosomiasis  and  is  transmitted  by  the 
tsetse  fly  (Glossinia)  in  whose  body  it  has  an  incubative  period  of 
3  weeks,  and  filariasis,  which  is  transmitted  by  the  Culex  mosquito. 

This  group  has  been  separated  from  the  Typhus  Group,  since 
the  latter  diseases  are  carried  by  wingless  insects,  and  with  one 
exception  are  not  known  to  have  an  extracorporeal  cycle.  Both 
of  these  insect-borne  groups  of  diseases  may  be  expected  to  be 
augmented,  especially  in  the  tropics,  with  more  exact  knowledge. 

YELLOW  FEVER. 

Definition. — Yellow  fever  is  an  acute  infectious  disease,  charac- 
terized by  a  febrile  paroxysm  succeeded  by  a  brief  remission  and 
a  relapse.  It  is  associated  more  or  less  constantly  with  jaundice, 
and  tendency  to  hemorrhage  especially  into  the  stomach,  whence 
the  blood  is  vomited,  constituting  "black  vomit."  Neither  jaun- 
dice nor  black  vomit  is  essential  to  the  disease  (Tyson). 

Distribution. — Guiteras  gives  the  following  distribution:  (1) 
The  focal  zone,  including  Havana,  Vera  Cruz,  Rio  de  Janeiro,  and 
other  portions  of  the  east  coast  of  tropical  America;  previous  to 
3001  the  disease  was  constantly  present  in  all  of  the  larger  cities 
of  this  area;  (2)  The  perifocal  zone,  or  zone  of  periodic  epidemics, 
including  the  ports  on  the  i^tlantic  in  tropical  America  and  Africa; 
(3)  The  zone  of  accidental  epidemics,  between  45°  north  and  35° 

128 


THE   YELLOW   FEVER   GROUP.  129 

south  latitude.  It  is  also  found  in  the  interior  during  accidental 
or  periodic  epidemics,  but  very  rarely  at  a  height  greater  than 
1,000  feet  above  sea-level. 

Etiology. — The  specific  morbific  organism  is  supposed  to  be  an 
ultramicroscopic  protozoon,  and  is  known  to  be  transmitted  in 
nature  only  by  mosquitoes  of  the  genus  Stegomyia  and  usually  by 
S.  fascdata.  Not  all  of  the  Stegomyine  mosquitoes  are  knoAvn  to  be 
capable  of  transmitting  this  fever,  but  all  should  rest  under  sus- 
picion. An  interval  of  at  least  12  days  after  the  mosquito  receives 
the  infected  bloo'd  is  necessary  before  its  bite  becomes  dangerous  to 
a  non-immune.  Yellow  fever  is  never  conveyed  by  fomites  or  direct 
infection,  except  by  experimental  inoculation  of  the  non-immune 
by  sub-cutaneous  injection  of  yellow  fever  blood. 

Predisposition. — Yellow  fever  attacks  all  ages,  races  and  nation- 
alities, but  negroes  rather  less  frequently  than  whites.  Males  are 
more  often  infected  than  females,  since  their  work  renders^  them 
more  likely  to  be  bitten  by  mosquitoes. 

Incubation. — In  experimental  cases  the  incubation  period  has 
varied  from  41  to  137  hours. 

Immunity. — .One  attack  usually  protects.  There  is  no  method 
of  securing  artificial  immunity. 

Pathology. — Intense  jaundice  and  subcutaneous  hemorrhages 
are  generally  present.  The  blood  is  partly  "laked";  i.e.,  its 
hemoglobin  is  partially  dissolved  in  the  serum.  The  liver  is  brown, 
with  a  "coffee  and  cream"  color,  and  is  frequently  fatty.  The 
kidneys  often  present  cloudy  swelling  or  an  actual  nephritis. 
After  death  the  stomach  contains  more  or  less  extravasated  blood, 
the  mucous  membrane  is  congested  and  swollen.  Yellow  fever 
cannot  be  diagnosed  post-mortem  unless  the  history  of  the  case  is 
known. 

Symptoms. — Stage  of  Invasion.  (Febrile  Stage). — Onset  sud- 
den, generally  with  chill,  followed  by  headache,  pain  in  back,  and 
aching  of  the  limbs.  It  may  begin  at  any  time  of  day,  but  more 
frequently  begins  at  night  while  the  patient  is  relaxed.  The  fever 
rises  quickly  to  a  point  between  102°  and  105°  and  the  pulse  at 
first  corresponds  but  on  the  second  or  third  day  begins  to  fall  and 
may  drop  as  many  as  20  beats  per  minute  even  while  thip  tempera- 
ture rises.  The  skin  is  hot  and  dry,  but  not  as  much  so  as  in  typhus. 
As  early  as  the  first  day  the  face  is  flushed,  the  eyes  reddened,  the 
lips  slightly  swollen,  the  tongue  covered  "with  a  moist  fur,  the 


130  PRACTICAL  SANITATION. 

throat  sore,  the  bowels  constipated,  the  urine  scanty  and  often 
albuminous,  though  albuminuria  is  not  regularly  present  till  the 
third  day. 

Nausea  may  be  present  from  the  beginning,  but  black  vomit  is 
not  seen  until  the  second  or  third  day.  This  is  often  compared  to 
coffee,  and  the  sediment  to  the  grounds.  In  the  worst  cases  it  is 
tarry  black.  It  consists  of  broken  down  red  cells  and  pigment. 
The  febrile  stage  lasts  from  a  few  hours  to  3  days. 

Stage  of  Calm. — The  fever  declines  for  a  few  hours  or  a  day 
or  two  in  severe  cases,  and  in  mild  cases  convalescence  may  date 
from  this  stage,  but  ordinarily  it  merges  into  the  third  stage  or 
stage  of  febrile  reaction. 

Stage  op  Febrile  Reaction. — •This  lasts  from  1  to  3  days.  The 
temperature  again  rises,  although  the  pulse  may  continue  to  fall. 
The  nausea  and  vomiting  return,  the  latter  becomes  again  hemor- 
rhagic, and  there  may  be  pain  in  the  abdomen.  The  feces  are 
black  and  offensive.  If  jaundice  has  not  been  present,  it  now 
makes  its  appearance,  the  tongue  becomes  dry  and  brown,  there 
may  be  bleeding  from  any  or  all  mucous  membranes.  To  albu- 
minuria may  be  added  hematuria.  The  strength  fails,  the  pulse 
grows  weaker,  there  are  tremblings,  suppression  of  the  urine,  de- 
lirium, convulsions  or  stupor  and  death. 

The  termination  is  not  inevitably  fatal,  even  when  black  vomit 
is  seen.  The  symptoms  may  gradually  subside  and  convalescence 
take  place  though  the  jaundice  may  remain  for  a  long  time. 

Diagnosis. — The  three  characteristic  symptoms  are:  early  jaun- 
dice, early  albuminuria,  and  the  slowing  of  the  pulse  with  stationary 
or  rising  temperature.  During  defervescence,  the  pulse  may  go 
as  low  as  30  beats  per  minute,  while  at  the  height  of  the  fever,  with 
a  temperature  of  104°,  the  pulse  may  be  as  low  as  70  or  80. 

Prognosis. — In  various  epidemics  the  mortality  has  varied  be- 
tween 15  and  85  per  cent  so  that  it  is  an  exceedingly  grave  disease. 
It  is  greatest  in  the  feeble,  the  dissipated  and  the  poor.    - 

Prevalence. — ^In  the  quinquennium  from  1901  to  1905  there  was 
an  average  mortality  of  95  in  the  registration  area  of  the  United 
States,  practically  all  of  it  concentrated  in  the  one  year  1905,  when 
438  deaths  occurred.  In  1907  and  1008  there  were  1  and  2  deaths 
respectively,  and  in  other  years  of  the  century  none. 

Prophylaxis. —  (1)  The  non-immune  must  be  guarded  against 
the  mosquito. 


THE  YELLOW  FEVER  GROUP.  131 

(2)  The  sick  must  be  protected  against  the  mosquito  in  a  care- 
fully screened  room  in  order  to  prevent  infection  of  the  mosquito. 

(3)  Mosquitoes  and  their  larvae  must  be  destroyed  by  the  meth- 
ods detailed  in  the  special  chapter  on  the  subject,  page  286. 

These  simple  methods  have  eradicated  yellow  fever  wherever 
they  have  been  conscientiously  applied,  as  in  Havana  and  Panama, 
by  the  Medical  Department  of  the  United  States  Army.  By  their 
use  such  drastic  measures  as  depopulation  are  not  necessary.  Here- 
tofore the  non-immunes  have  been  sent  to  uninfected  and  unin- 
habited places  to  prevent  the  spread  of  certain  epidemics. 

Quarantine. — Quarantine  for  the  sick  is  of  no  value  unless  the 
patient  is  isolated  in  a  mosquito-proof  room  or  apartment.  For 
persons  coming  into  the  United  States  from  infected  ports  a  quaran- 
tine of  6  days  is  required,  and  the  same  period  is  necessary  for 
contacts. 

Disinfection. — ^No  disinfection  is  of  value  which  does  not  kill 
the  mosquito.  Sulphur  or  hydrocyanic  acid  may  be  used,  or 
pyrethrum  (ordinary  insect  powder)  burned  in  the  room.  This 
last  method  merely  stupefies  the  mosquitoes,  which  must  be  swept 
up  and  burned. 

MALARIA. 

Synonyms. — Ague;  Fever  and  Ague;  Chills  and  Fever;  Marsh 
Fever;  Swamp  Fever;  Paludal  Fever;  Miasmatic  Fever;  Intermit- 
tent, Remittent,  and  Pernicious  Remittent  Fever;  Bilious  Fever; 
Estivoautumnal  Fever;  Paludism. 

Definition. — The  malarial  fevers  are  a  group  of  fevers  of  inter- 
mittent or  remittent  type  due  to  infection  by  the  various  species  of 
Plasmodium,  a  parasitic  protozoon,  and  which  owe  their  peculiar 
characteristics  of  paroxysms  or  continued  fever  to  the  intermittent 
or  continuous  sporulation  of  the  parasite.  This  disease  is  trans- 
mitted only  by  the  mosquitoes  of  the  genus  Anopheles,  and  appar-  c""  -  - 
ently  not  by  all  the  species  of  this  genus.  7" 

Distribution. — ^INlalaria  was  formerly  spread  over  the  whole  of 
Europe,  but  is  now  rare  except  in  southern  Russia  and  Italy.  It 
is  to  be  found  in  most  parts  of  the  United  States,  even  in  the  arid 
portions,  wherever  the  Anopheles  has  established  itself  and  found 
human  carriers  of  the  parasite.  It  is  universal  in  the  parts  of  the 
tropics  having  much  rainfall,  except  on  certain  islands  where  the 
mosquito  has  not  yet  reached.     It  is  particularly  deadly  in  certain 


132  PRACTICAL   SANITATION. 

parts  of  Africa,  in  India,  and  was  formerly  so  in  Panama  before 
the  energetic  antimosquito  campaign  at  the  beginning  of  the  con- 
struction of  the  Canal. 

Etiolog"y. — The  three  known  species  of  the  Plasmodium  are  as 
follows : 

Plasmodium  Vivax. — The  parasite  of  Tertian  Fever.  The  earli- 
est form  fomid  in  the  human  blood  is  about  2  mi.  in  diameter, 
round  or  irregular  in  shape,  without  pigment.  It  corresponds  to 
one  segment  of  the  rosettes  hereafter  to  be  described.  A  few  hours 
later  the  parasite  is  larger  but  still  retains  the  ring  shape  and  con- 
tains fine  pigment  grains.  There  is  a  large  nuclear  body  and 
opposite  it  a  body  of  chromatin,  which  stains  deeply  with  the 
proper  stains.  It  is  now  actively  ameboid  and  shows  tongue-shaped 
protrusions  of  protoplasm.  The  parasite  continues  to  grow  until  at 
the  end  of  48  hours  it  has  grown  beyond  the  normal  dimensions  of 
the  red  cell  which  forms  its  home.  Between  the  fortieth  and  forty- 
eighth  hours  it  may  be  seen  undergoing  segmentation,  in  which  all 
the  pigment  is  collected  into  a  mass,  while  the  Plasmodium  divides 
into  from  15  to  20  spores,  arranged  radially  and  forming  the  rosette. 
Not  all  the  plasmodia  segment  in  this  manner,  but  some  become 
enlarged  and  retain  their  pigment,  which  is  in  active  motion.  These 
large  parasites  are  the  sexual  form  the  gametocytes,  and  are  des- 
tined only  to  perform  their  part  in  the  transmission  of  the  disease 
in  case  they  are  taken  into  the  body  of  the  Anopheles  mosquito. 

Plasmodium  Malaria. — The  parasite  of  Quartan  Fever.  This 
somewhat  resembles  the  tertian  parasite,  but  the  pigment  granules 
are  coarser  and  darker.  By  the  second  day  the  parasite  is  larger 
than  the  tertian,  shows  little  ameboid  motion,  and  the  pigment  is 
peripheral  rather  than  diffused.  The  rim  of  protoplasm  around 
the  outside  is  deep  yellowish-green  or  brassy  in  color.  On  the  third 
day,  sporulation  begins,  the  segments  being  from  6  to  12,  and  some 
of  the  parasites  persisting  without  segmentation  to  form  the 
gametocvtes. 

Plasmodium  Precox. — The  parasite  of  estivoautumnal  fever. 
This  is  considerably  smaller  than  the  other  two  varieties;  at  full 
development  it  is  often  not  more  than  one-half  the  size  of  a  red 
cell.  The  pigment  is  much  scantier,  often  forming  only  a  few 
scant  granules.  The  earlier  stages  of  development  present  only 
small  hyaline  bodies,  perhaps  with  a  pigment  granule  or  two,  in 
the  peripheral  circulation.     The  later  stages  are  to  be  found  in  the 


THE  YELLOW  FEVER  GROUP.  133 

spleen,  bone  marrow,  and  perhaps  the  brain.  The  corpuscles  con- 
taining the  parasites  are  often  shrunken,  brassy  and  crenated. 
After  the  process  has  gone  on  for  about  a  week,  larger,  refractive, 
crescentic,  ovoid  and  round  bodies  appear.  These  are  the  charac- 
teristic Plasmodium  forms  of  estivoautumnal  fever,  and  are  the 
gametocytes.  In  the  blood  they  undergo  no  further  development, 
but  in  the  mosquito,  the  male  gametocytes  segment  to  form  the 
microgametes,  and  the  female  to  form  the  macrogametes.  The 
microgametes  penetrate  the  cell  wall  of  the  macrogametes  and 
fecundate  the  female  in  this  manner.  The  fecundated  female  para- 
site then  penetrates  the  stomach  wall  of  the  mosquito  and  there 
undergoes  a  regular  cycle  of  development  which  fits  it  to  be  rein- 
oculated  into  the  human  species.  Much  of  this  process  can  be  wit- 
nessed on  the  warm  stage  of  the  microscope. 

In  addition  to  these  three  known  forms,  there  is  reason  to  be- 
lieve in  a  fourth,  which  is  responsible  for  the  dreaded  blackwater 
or  hematuric  fever  of  the  tropics  and  our  own  Southern  States. 

Patholog-y. — Simple  malarial  fevers  are  rarely  fatal,  and  what 
we  know  of  the  disease  is  largely  drawn  from  autopsies  on  victims 
of  pernicious  malaria  or  malarial  cachexia. 

Pernicious  Malaria. — The  blood  is  watery  and  the  serum  ma}*- 
contain  free  hemoglobin.  The  red  cells  are  heavily  infected  with 
the  parasite  and  are  to  be  found  in  all  stages  of  destruction.  The 
spleen  is  enlarged,  often  only  moderately.  In  a  fresh  infection, 
the  spleen  is  pulpy  and  soft  and  often  laked  by  free  hemoglobin. 
When  choleraic  symptoms  are  present,  the  gastrointestinal  capil- 
laries may  be  found  choked  with  the  parasites. 

Malarial  Cachexia. — Death  usually  results  from  anemia  or 
hemorrhage,  the  anemia  being  particularly  profound  if  the  patient 
has  died  of  fever.  The  spleen  is  greatly  enlarged,  sometimes 
weighing  7  to  10  lbs.  The  liver  is  greatly  enlarged  and  slaty-gray 
in  color.  Melanin  is  present  around  the  portal  canals  and  under 
the  capsule.  The  kidneys,  peritoneum,  and  mucous  membrane  of 
the  stomach  and  intestines  may  also  be  stained  with  melanin,  which 
is  a  decomposition  product  of  hemoglobin. 

Malarial  hepatitis,  pneumonia  and  nephritis  are  accidental  rather 
than  regular  accompaniments  of  the  disease,  although  Osier  states 
that  in  his  cases  of  estivoautumnal  fever,  nephritis  was  present  in 
4.5  per  cent  and  albuminuria  of  moderate  amount  in  46.4  per  cent 
of  the  same  class  of  cases. 


134  PRACTICAL   SANITATION. 

Clinical  Course. — Tertian  and  Quartan  Intermittents. — The 
incubation  period  as  determined  experimentally  is  from  36  hours 
to  15  days. 

Prodromes. — The  patient  knows  a  few  hours  before  that  he  will 
have  a  chill,  on  account  of  a  peculiar  feeling  of  uneasiness,  with 
lassitude  and  often  with  headache. 

Cold  Stage. — The  lassitude  increases,  the  patient  yawns  and 
stretches,  and  the  thermometer  in  mouth  or  rectum  indicates  a 
slight  rise  in  temperature.  The  patient  begins  to  shiver,  the  body 
becomes  blue  and  cold,  and  the  surface  temperature  is  reduced, 
although  the  rectal  temperature  at  the  same  time  is  105°  or  106°. 
There  may  be  nausea,  vomiting  and  intense  headache.  The  pulse 
is  quick,  small  and  hard.  This  continues  for  a  few  minutes  to  an 
hour  or  longer,  and  passes  over  into  the  hot  stage. 

Hot  Stage. — This  is  ushered  in  by  a  few  hot  flashes,  the  surface 
gradually  becomes  flushed,  hot  and  dry ;  the  pulse  is  full  and  bound- 
ing, and  the  heart's  action  is  forcible.  There  may  be  pain  over 
the  liver  and  a  throbbing  headache.  Delirium  is  sometimes  seen. 
The  temperature  in  the  rectum  is  no  higher  than  in  the  cold  stage 
and  may  be  lower.  This  stage  lasts  for  3  or  4  hours  and  is  accom- 
panied by  the  most  tormenting  thirst.  This  picture  changes  rather 
abruptly  as  a  rule  for  that  of  the  sweating  stage. 

Sweating  Stage. — Drops  of  sweat  appear  on  the  face  and  grad- 
ually the  whole  body  becomes  bathed  in  moisture.  The  sweating 
may  be  drenching  or  slight,  but  with  its  appearance  the  uncom- 
fortable symptoms  subside  and  the  patient  falls  into  a  sound  and 
refreshing  sleep  as  a  general  thing. 

These  paroxysms  are  repeated  every  other  day  in  tertian  fever 
and  every  fourth  day  in  quartan  fever,  but  there  may  be  double 
or  mixed  infections  whereby  successive  crops  of  the  parasites 
mature  daily,  twice  daily,  on  two  successive  days  with  an  interval 
of  a  free  day,  and  so  on. 

Course  of  the  Disease. — After  a  few  paroxysms  the  patient  may 
recover  without  medication.  The  infection  may  persist  for  years, 
and  relapses  are  common,  frequently  following  accidents  or  oper- 
ations involving  loss  of  blood,  or  childbirth.  Persistent  fevers  of 
this  type  may  cause  anemia  and  malarial  cachexia. 

Estivoautumnal  Fever. — This  type  of  fever  is  irregular  and 
remittent  rather  than  intermittent  as  a  rule.     It  may  resemble  the 


THE   YELLOW   PEVER   GROUP.  135 

double  or  triple  infections  alluded  to  above,  and  the  paroxysms 
are  not  nearly  so  apt  to  show  the  three  stages,  either  the  cold  or 
sweating  stage  or  both,  being  at  times  absent  for  several  days. 
The  rise  in  temperature  and  its  decline  are  apt  to  be  slow  and 
gradual,  and  the  paroxysms  may  anticipate — come  daily  at  an 
earlier  hour.  The  type  of  fever  is  more  like  that  of  typhoid  than 
the  other  malarial  fevers  and  may  be  continuous  or  remittent. 
The  cases  vary  much  in  severity,  and  may  be  very  light  or  per- 
nicious, or  with  choleraic  symptoms.  The  confusion  in  the  diag- 
nosis of  this  fever  is  added  to  by  the  fact  that  it  occurs  in  the 
autumn  when  typhoid  is  apt  to  be  prevalent,  and  it  should  not  be 
forgotten  that  both  infections  may  co-exist. 

Diagnosis. — This  is  made  by  blood  examination,  the  fresh  blood 
being  preferable,  examined  before  coagulation.  Dried  specimens, 
unstained  or  stained  will  also  show  the  parasites.  By  the  micro- 
scope it  is  possible  to  differentiate  a  double  tertian  from  a  triple 
quartan  and  both  from  an  estivoautumnal,  and  all  three  from 
typhoid.  The  "Widal  reaction  should  not  be  omitted  as  a  malaria 
may  be  succeeded  or  accompanied  by  a  typhoid. 

Prophylaxis. — This  is  to  be  obtained  in  two  ways ;  by  destroying 
the  parasite  in  the  bodies  of  its  human  carriers — especially  in  chil- 
dren who  often  have  malaria  without  much  disturbance — by  the 
persistent  use  of  quinine,  and  in  grave  cases,  the  organic  arsenic 
compounds ;  and  by  destroying  the  Anopheles  mosquitoes  wherever 
found,  as  is  more  fully  described  in  the  special  chapter  on  the  sub- 
ject (page  286). 

DENGUE. 

Synonyms. — Breakbone  Fever;  Dandy  Fever. 

Definition. — Dengue  is  an  acute  epidemic  infectious  disease  whose 
cause  is  unknown  but  which  is  spread  by  mosquitoes  of  the  genus 
Gulex.  It  is  characterized  by  paroxysms  of  severe  pain  in  the 
joints  and  muscles,  aggravated  by  motion  and  accompanied  often 
by  great  hyperesthesia.  Fever  is  present  and  frequently  eruptions 
of  the  skin  are  seen. 

Etiology. — Various  observers  have  found  bacterial  organisms, 
usually  micrococci,  but  careful  work  has  failed  to  confirm  these  ob- 
servations. Both  sexes  and  all  ages  are  attacked,  but  the  disease 
is  limited  to  warm  countries  or  warm  seasons. 


136  PRACTICAL   SANITATION. 

Incubation. — 3  to  5  days. 

Immunity. — One  attack  generally  protects,  but  second  or  third 
attacks  are  sometimes  seen. 

Symptoms. — The  onset  is  sudden,  so  abrupt  that  the  Spanish 
call  it  Trancaso  "A  blow  with  a  club."  It  frequently  comes  at 
night,  and  the  patient,  who  has  previously  felt  perfectly  well  or 
has  suffered  from  only  slight  malaise,  slight  headache  or  chilliness, 
finds  himself  in  severe  or  even  agonizing  pain,  which  may  involve 
the  head,  loins,  joints,  muscles  or  the  whole  body.  A  peculiar  and 
very  characteristic  symptom  is  the  great  hyperesthesia  of  some 
part  of  the  body,  particularly  the  soles  of  the  feet,  so  that  to  have 
them  touched  is  torture. 

The  fever  is  high,. sometimes  to  105°  or  106°,  the  maximum  oc- 
curring on  the  second  to  the  fourth  days,  and  declining  to  normal 
on  the  fifth  day,  when  the  symptoms  all  subside  and  the  patient 
has  a  respite  of  a  day  or  perhaps  two  when  all  the  symptoms  except 
sometimes  the  hyperesthesia  subside.  At  the  end  of  this  time,  the 
symptoms  recur,  generally  in  somewhat  milder  form,  to  continue 
for  another  3  or  4  days,  when  convalescence  sets  in. 

Delirium  is  rare  except  in  children.  The  tongue  is  coated  and 
red  at  the  tip  and  edges ;  the  appetite  is  lost  or  impaired,  there  are 
slight  nausea,  thirst,  scanty  urine,  and  constipation.  During  both 
paroxysms  a  rash  resembling  measles  is  present,  according  to  per- 
sonal experience,  and  the  eyes  may  be  reddened.  The  lymphatics 
of  the  neck,  groin  and  other  parts  of  the  body  are  always  swollen 
and  painful. 

A  peculiar  sequela  often  seen  is  a  single  painful  joint,  often  of 
a  finger  or  toe,  which  may  remain  for  weeks. 

Diagnosis. — The  rash  and  the  swollen  lymphatics,  together  with 
the  fact  that  the  patient  is  not  prostrated  as  one  would  expect  with 
the  severity  of  the  symptoms,  will  fix  the  diagnosis. 

Prognosis. — Death  is  very  rare,  but  a  poor  state  of  health  may 
persist  for  some  time. 

Prophylaxis. — As  for  yellow  fever. 

Quarantine. — Quarantine  and  disinfection  are  not  requirecl. 


CHAPTEE  XI. 

THE  SEPTIC  GROUP. 

This  group  contains  besides  the  two  diseases  treated  in  full,  sep- 
ticemia and  pyemia,  puerperal  fever,  and  hospital  gangrene.  All 
are  infections  of  wounds  or  abrasions  in  most  instances,  and  all  are 
preventable  in  any  case  which  would  concern  the  sanitarian  as 
such  by  the  application  of  the  principles  of  surgical  cleanliness. 
The  etiology  of  the  last  four  embraces  also  other  infections  than 
those  of  the  streptococcus,  as  the  terms  are  usually  applied.  For 
these  reasons  their  detailed  consideration  is  omitted. 

ERYSIPELAS. 

Synonyms. — ^The  Rose;  St.  Anthony's  Fire. 

Definition. — An  acute  contagious  dermatitis  caused  by  infection 
with  the  Streptococcus  erysipelatis  {S.  pyogenes),  and  associated 
with  the  usual  signs  of  dermatitis,  heat,  swelling,  pain,  redness  and 
a  disposition  to  spread. 

Etiology. — The  infecting  agent  is  a  micrococcus,  3  to  4  mi.  in 
diameter,  the  cells  of  which  are  associated  in  chains  of  from  2  to 
12  or  more  members.  This  organism  is  introduced  through  some 
abrasion  or  gains  entrance  to  the  deeper  layers  of  the  skin  through 
a  hair  follicle  or  sweat  gland,  and  multiplies  in  the  lymph  spaces 
at  first,  afterwards  passing  into  the  blood  stream,  by  which  means 
it  not  infrequently  infects  distant  parts.  It  is  transmitted  by  con- 
tact, by  infected  articles  or  the  hands  of  surgeons  and  nurses,  and 
is  believed,  especially  by  surgeons,  to  cling  to  walls,  bedding,  in- 
fected articles  or  hands  for  a  considerable  time.  Aerial  carriage 
is  not  likely  to  occur  except  in  cases  of  erysipelas  involving  the 
nose  or  mouth,  in  which  droplet  infection  in  coughing  or  sneezing 
might  readily  occur. 

Incubation. — ^1  to  8  days;  accidental  inoculations  have  shown  an 
incubation  period  of  only  a  few  hours. 

Immunity. — Many  people  are  not  susceptible  to  the  disease  ex- 
cept by  accidental  inoculation;  an  antistreptococcic  serum  is  made 

137 


138  PRACTICAL.   SANITATION. 

which  has  produced  rapid  improvement  in  erysipelas,  and  which 
might  well  be  used  in  cases  where  infection  is  thought  to  have  oc- 
curred but  in  which  the  disease  has  not  yet  appeared.  Vaccines 
after  AVright's  method  are  also  made  and  employed  with  alleged 
good  results.  In  connection  with  vaccines  and  sera,  it  is  to  be 
remembered  that  there  are  several  strains  of  the  streptococcus,  and 
that  the  products  made  from  one  strain  will  not  be  as  effective 
against  other  strains.  Most  of  these  are  made  from  a  combination 
of  several  strains,  and  are  "polyvalent." 

Symptoms. — The  first  symptom  is  a  chill  or  succession  of  chills, 
with  elevation  of  temperature  and  loss  of  appetite.  A  small  ele- 
vated dusky  red  spot  appears  at  the  point  of  the  initial  lesion,  which 
enlarges,  with  sharply  defined  edges,  maintaining  its  elevation 
above  the  surrounding  skin. 

Fever  is  pronounced,  reaching  105°  or  higher  at  times,  and  is 
associated  with  headache,  frequent  pulse,  and  in  the  more  serious 
cases  with  delirium  and  the  typhoid  state. 

Termination  is  usually  by  crisis  at  from  the  third  to  the  fifth 
day,  and  the  temperature  remains  at  or  near  normal  unless  the  in- 
fection is  relighted. 

The  complications  are  focal  lesions  due  to  cocci  carried  in  the 
blood  stream,  and  are  endocarditis,  meningitis,  deep  abscesses,  gan- 
grene, septic  nephritis,  and  pyemia  or  septicemia.  Meningitis  may 
occur  by  extension  along  the  sheaths  of  the  cranial  nerves. 

The  disease  has  a  rather  marked  tendency  to  relapse  or  recur, 
repeated  attacks  not  being  uncommon. 

Prophylaxis. — Strict  cleanliness  is  probably  the  only  prophylactic 
measure  necessary  to  prevent  the  spread  of  cutaneous  erysipelas, 
but  physicians  in  charge  of  such  eases  should  not  attend  surgical 
or  obstetrical  cases  without  the  most  thorough  disinfection  of  the 
person,  change  of  clothing,  and  the  use  of  long  rubber  gloves. 
Rooms  in  which  such  cases  have  occurred  should  be  disinfected  be- 
fore either  of  the  above  classes  of  cases  is  admitted  into  them,  since 
septicemia,  pyemia,  puerperal  fever,  and  probably  such  cases  of 
the  formerly  terrible  hospital  gangrene  as  are  not  due  to  the  cap- 
sule bacillus  (B.  aerogenes  capsulatus)  are  almost  always  strep- 
tococcic infections. 

Isolation  of  the  patient  is  desirable,  but  quarantine  is  not  re- 
quired. 


THE    SEPTIC    GROUP.  139 

TETANUS. 

Synonym. — Lockjaw. 

Definition. — An  infectious  disease  caused  by  the  inoculation  and 
growth  of  the  Bacillus  tetani,  which  is  normally  found  in  soil,  in 
putrefying  fluids,  in  manure,  and  in  the  alimentary  canal  of  herbiv- 
orous animals.  It  is  characterized  by  tonic  spasms  of  the  muscles, 
with  acute  exacerbations. 

Etiology. — The  morbific  agent  is  the  one  noted  in  the  definition, 
which  gains  entrance  through  a  wound,  and  there  multiplies,  al- 
though in  the  so-called  idiopathic  tetanus  no  wound  is  discoverable. 

The  bacillus  of  tetanus  is  a  slender  rod  with  rounded  ends,  non- 
motile,  completely  anserobic,  and  is  spore-bearing.  The  bacilli  with 
included  spores  resemble  a  drumstick  or  round-headed  tack  in 
shape.  It  is  not  killed  by  a  temperature  of  176°  in  the  actively 
growing  state,  while  the  spores  are  highly  resistant  to  heat  and 
drying.  Unless  in  deeply  punctured  wounds,  aerobic  pus-germs 
must  also  be  present  to  take  up  the  available  supply  of  oxygen, 
or  the  tetanus  bacillus  is  unable  to  multiply. 

They  do  not  ordinarily  pass  into  the  circulation,  but  remain 
sharply  localized  at  the  point  of  inoculation.  Hence  the  disease 
is  due  to  the  toxins  given  off,  which  pass  into  the  circulation  and 
become  fixed  in  the  protoplasm  of  nervous  tissue,  causing  the  char- 
acteristic symptoms.  This  has  often  been  proved  by  the  injection 
of  the  filtered  products  of  the  growth  of  the  bacilli.  These  are 
several  in  number,  and  comprise  at  least  two  alkaloidal  bodies  and 
one  toxalbumin,  and  owing  to  their  various  actions,  diiferent  clinical 
pictures  are  shown  as  one  or  the  other  predominates. 

Certain  localities  are  unenviably  notorious  for  the  number  of 
eases  of  tetanus,  and  the  disease  occasionally  becomes  epidemic. 

Pathology. — Nothing  distinctive  is  found  post-mortem. 

Incubation. — ^From  5  to  15  days. 

Symptoms. — Rarely  a  chill  presages  the  disease.  Usually  the 
first  sigTi  is  a  stiffening  of  the  neck  and  muscles  of  the  jaws.  The 
patient  opens  the  mouth  with  difficulty.  This  stiffness  then  ex- 
tends to  the  back,  abdomen,  and  muscles  of  the  extremities,  and 
when  complete  the  whole  body  is  held  rigid  in  either  a  straight  or 
flexed  position  as  though  it  were  of  wood  (Tyson).  The  jaws  in 
severe  cases  become  locked,  but  are  sometimes  possible  to  open 
forcibly.     The  eyebrows  are  raised,  and  the  corners  of  the  mouth 


140  PRACTICAL,   SANITATION. 

also,  producing  the  so-called  "sardonic  grin."  This  is  not  always 
present  even  in  fatal  cases.  In  other  cases  the  clonic  convulsions 
may  take  the  place  of  the  extreme  tonic  spasm,  and  death  may 
occur,  as  in  a  personal  case,  in  the  first  convulsion  before  more 
than  a  slight  stiffening  of  the  jaw  and  neck  muscles  had  occurred. 
Both  tonic  and  clonic  spasms  are  very  painful  and  are  aggravated 
by  slight  stimuli. 

The  temperature  is  usually  not  over  102°  but  may  go  to  105° 
or  even  110°.  The  pulse  is  very  rapid,  130  to  150,  and  the  respira- 
tions are  from  30  to  50  per  minute. 

Diagnosis. — Tetanus  is  differentiated  from  strychnine  poisoning 
by  the  absence  of  rigidity  between  the  paroxysms,  by  the  greater 
involvement  of  the  extremities,  by  the  history  of  the  case,  and  by 
the  absence  of  lockjaw  in  the  latter  condition.  A  comparison  of 
the  symptoms  of  hydrophobia  (see  page  125)  will  readily  enable 
that  disease  to  be  excluded;  cerebrospinal  fever  (page  159)  and 
parotitis  (page  113)  will  seldom  give  rise  to  difficulty. 

Prognosis. — Of  traumatic  tetanus  cases  about  80  per  cent  die, 
but  of  the  idiopathic  cases  less  than  50  per  cent.  Since  the  focus 
of  infection  in  the  latter  cases  is  not  discoverable,  naturally  it  is 
usually  smaller,  the  amount  of  toxins  produced  is  smaller,  and  death 
is  less  frequent  because  a  small  dose  kills  less  often  than  a  large 
one.     Incubation  periods  under  8  days  are  very  unfavorable. 

Prevalence. — The  number  of  deaths  in  the  registration  area  is 
very  uniform,  having  stood  at  a  point  in  the  neighborhood  of  1,150 
for  9  years  past.  Recent  statistics  show  a  marked  improvement  for 
the  country  at  large  in  a  single  class  of  tetanus  cases,  those  due 
to  accidents  with  explosives  on  July  4th.  In  1903  these  presented 
the  grim  total  of  415,  in  1908,  76,  while  the  ''Sane  Fourth"  idea, 
together  with  prompt  cleansing  and  opening  of  wounds  and  the 
administration  of  antitoxin,  reduced  the  mortality  in  1911  almost 
to  -the  vanishing  point.  In  Great  Britain,  on  the  contrary,  it  is 
rising  for  some  unknown  reason. 

Prophylaxis. — ^In  addition  to  the  opening  and  loose  packing  of 
all  wounds  likely  to  become  infected,  hydrogen  dioxide  should  be 
freely  used  as  supplying  large  quantities  of  oxygen  within  the 
wound,  and  prophjdactic  doses  of  antitetanic  serum  should  be  em- 
ployed. Owing  to  the  fixation  of  the  poison  within  the  nerve  tis- 
sues, the  curative  use  of  the  serum  is  likely  to  disappoint. 

No  isolation,  quarantine  or  disinfection  is  necessary. 


CHAPTER  XII. 

THE  TUBERCULOSIS  GROUP. 

The  two  diseases  in  this  group,  tuberculosis  and  leprosy,  have 
much  in  common.  Both  are  the  result  of  infection  by  acid-fast 
bacilli,  both  are  highly  chronic,  not  highly  infectious,  have  a  very 
long  incubation  period,  are  difficult  to  treat  when  well  established, 
and  have  many  pathological  features  in  common.  They  thus  form 
a  very  natural  epidemiological  group. 

TUBERCULOSIS. 

Definition. — An  infective  disease  caused  by  Bacillus  tuberculosis, 
the  lesions  of  which  are  characterized  by  nodular  bodies  called 
tubercles  or  diffuse  infiltrations  of  tuberculosis  tissue  which  un- 
dergo caseation  or  sclerosis  and  may  finally  ulcerate,  or  in  some 
cases  calcify  (Osier). 

Etiology. — Tuberculosis  is  an  exceedingly  widespread  malady, 
affecting  almost  all  warm-blooded  animals  under  proper  conditions. 
Cold-blooded  animals  are  practically  immune,  since  their  body  tem- 
perature is  below  that  required  for  the  development  of  the  bacillus. 
To  the  sanitarian,  the  salient  feature  is  the  frequent  infection  of 
bovine  animals,  upon  whom  man  depends  so  largely  for  meat  and 
milk. 

Tuberculosis  is  the  most  wide-spread  of  all  the  infectious  dis- 
eases, being  responsible  for  78,289  deaths  in  1908  in  the  Registra- 
tion Area  of  the  United  States,  a  mortality  rate  of  173.9  per 
100,000 ;  67,376  of  which  were  tuberculosis  of  the  lungs,  with  a 
rate  of  149.6  per  100,000.  The  death-rate  from  tuberculosis  is 
steadily  decreasing,  having  decreased  every  year  from  1904,  when 
it  was  201.6  per  100,000,  to  1908,  when  the  figiires  were  as  above 
quoted.  It  is  an  urban,  rather  than  a  rural  disease,  as  shown  by 
the  fact  that  the  cities  in  registration  States  give  a  rate  of  198.3 
while  the  rural  parts  of  the  same  States  show  only  136.6  per  100,000 
(1908). 

From  1890  to  1900,  the  death-rate  from  pulmonary  consumption 

141 


142  PRACTICAL  SANITATION. 

in  the  whole  United  States  registered  a  fall  of  22.4  per  cent  while 
the  general  death-rate  fell  only  9.4.  Similar  statistics  are  available 
from  many  sources,  but  those  shown  are  sufficient  to  demonstrate 
that  tuberculosis  is  not  only  a  preventable  disease,  but  is  actually 
being  prevented. 

Race. — Indians  and  negroes  are  particularly  susceptible  to  the 
various  forms  of  tuberculosis,  while  the  Irish  among  white  peoples 
seem  to  be  more  liable  than  their  neighbors.  Jews,  who  were  for 
2,000  years  urban  dwellers,  and  who  may  be  supposed  to  be  well 
adapted  to  city  life,  have  a  mortality  of  only  about  half  that  of 
their  Christian  neighbors. 

Bacillus  Tuberculosis. — ^The  bacillus  of  tuberculosis  is  a  short 
fine  rod,  often  slightly  bent  or  curved,  about  3  to  4  mi.  in  length. 
It  sometimes  branches  or  shows  lateral  outgrowths.  It  is  difficult 
to  stain,  requiring  a  mordant  to  fix  the  dye,  but  when  stained  the 
stain  is  not  attacked  by  dilute  acids,  which  fact  enables  the  bacillus 
to  be  readily  found  in  mixtures.  It  must  not  be  forgotten  that  a 
number  of  other  organisms  are  also  acid-fast,  although  the  only 
one  likely  to  be  confused  with  B.  tuberculosis  in  ordinary  work  is 
the  smegma  bacillus  in  urine  examinations. 

Modes  of  Infection. 

(1)  Congenital. — This  is  excessively  rare  so  far  as  absolutely 
proved  cases  go  and  may  be  dismissed  with  this  statement. 

(2)  Inoculation. — This  mode  of  infection  is  possible,  but  rarely 
produces  more  than  local  lesions  at  the  inoculation  site  or  involve- 
ment of  the  next  group  of  lymphatics. 

(3)  Inhalation. — This  is  possible  by  two  modes,  inhalation  of 
dried  dust  containing  bacilli  and  inhalation  of  droplets  thrown  off 
in  coughing,  sneezing  or  speaking.  This  is  beyond  question  an  im- 
portant avenue  of  infection,  but  of  the  two  possible  ways  in  which 
the  bacilli  may  be  air-borne  that  by  droplets  is  much  more  important. 
Dust  infection  is  possible  but  is  less  likely  to  occur  than  droplet 
infection. 

(4)  Ingestion. — The  bacilli  are  frequently  swallowed  in  food 
prepared  or  handled  by  the  tubercular,  in  milk  which  is  either  from 
tubercular  cows  or  infected  by  human  carriers,  and  perhaps  through 
putting  one's  own  fingers  into  the  mouth  after  they  have  been  in- 
fected from  some  source.  This  latter  Chapin  regards  as  the  im- 
portant method.     However  the  bacilli  enter  the  mouth,  they  may 


THE   TUBERCULOSIS   GROUP.  143 

infect  the  tonsils  and  secondarily  the  cervical  lymph  nodes,  the 
mediastinum,  the  lymph  channels  and  the  lungs.  Or  they  may 
be  taken  up  from  the  intestine  without  infecting  it  and  pass  to  the 
lungs  and  other  organs  in  the  lymph  stream.  Milk  is  very  often 
infected,  Hess  finding  16  per  cent  of  the  107  specimens  he  examined 
in  New  York  to  be  infected.  It  is  not  believed  that  milk  infection 
is  extremely  common,  however,  as  only  about  5  per  cent  of  all  cases 
of  tuberculosis  contain  the  bovine  type  of  bacilli. 

Conditions  Favoring  Infection. — Age  and  sex  present  but 
slight  influence.  The  main  factor  above  all  others  is  lack  of  fresh 
air,  however  it  is  produced.  Adenoids  and  enlarged  tonsils  or  en- 
larged turbinates  cut  off  fresh  air  from  the  individual,  as  also  do 
certain  heart  lesions.  Overcrowding  or  lack  of  ventilation,  espe- 
cially in  sleeping  rooms  cuts  off  oxygen  from  several  or  many.  It 
is  not  to  be  inferred  that  oxygen-starvation  is  the  only  factor  to 
consider,  but  it  is  an  index  which  cannot  be  neglected.  Animals 
free  from  tuberculosis  in  their  wild  life  become  quickly  victims  of 
the  disease  in  captivity.  The  same  is  true  of  races  of  men  accus- 
tomed to  a  free  life  when  they  become  town  dwellers. 

Pathology. — Distribution  of  Lesions. — In  children  the  lymph- 
nodes,  bones  and  joints  are  most  frequently  attacked;  in  adults, 
the  lungs.  Almost  every  tissue  of  the  body  has  been  found  at  some 
time  or  other  to  be  the  seat  of  tuberculosis  lesions.  While  the  whole 
subject  of  prevention  of  tuberculosis  is  important  to  the  sanitarian, 
the  two  forms  which  give  him  most  concern  are  pulmonary  tubercu- 
losis (phthisis  or  consumption)  and  tubercular  meningitis.  The 
first  is  important  because  it  is  a  source  of  infection  and  the  latter 
because  it  may  simulate  rather  closely  cerebrospinal  fever. 

Changes  Produced  by  the  Bacilli. — The  tubercle  is  not  a  lesion 
distinctive  of  tuberculosis,  since  similar  structures  are  found  in 
actinomycosis  and  other  parasitic  infections.  Baumgarten  gives 
the  following  history  of  the  development  of  the  tubercle: 

(a)  The  bacilli  multiply  rapidly  and  are  disseminated  in  the 
surrounding  tissues  by  growth  and  through  the  lymph  stream. 

(b)  The  fixed  cells  multiply  and  from  the  connective  tissue 
cells  and  capillary  endothelium  develop  variously  shaped  cells  with 
vesicular  nuclei,  the  epithelioid  cells,  inside  of  which  are  seen 
tubercle  bacilli. 

(c)  There  is  a  local  leucocytosis,  at  first  of  the  polynuclears  and 
afterwards  of  the  lymphocytes. 


144  PRACTICAL   SANITATION. 

(d)  A  reticulum  of  connective  tissue  fibrils  forms  which  can 
best  be  seen  at  the  edge  of  the  section  of  tubercle. 

(e)  Giant  cells  are  formed  in  some  tubercles,  not  in  all.  In  the 
chronic  varieties,  like  that  of  bone,  lymph-glands  and  the  skin 
(lupus),  these  giant  cells  are  rather  abundant,  but  in  acute  lesions 
are  rare  or  wanting. 

The  Degeneration  of  the  Tubercle. 

(a)  Caseation. — The  central  part  of  the  tubercle  coagulates,  the 
cells  lose  their  outline,  fail  to  stain  properly,  and  are  converted 
into  a  homogeneous  yellowish-gTay  mass,  in  which  no  blood  vessels 
are  to  be  seen.  These  chees}-  masses  may  suppurate,  become  encap: 
sulated,  or  calcified. 

(b)  Sclerosis. — In  place  of  the  softening  into  caseous  substance, 
the  fibrous  elements  may  multiply,  afterwards  undergoing  con- 
traction, until  only  a  hardened  mass  of  scar  tissue  is  left.  This 
is  the  favorable  termination.  Either  form  of  degeneration  may 
leave,  even  after  years,  bacilli  demonstrable  by  inoculation  into 
the  guinea-pig,  although  the  lesion  may  have  been  entirely  harm- 
less to  its  original  host  for  a  long  period.  Calcification  is  said  to 
occur  with  much  greater  frequency  when  the  infecting  bacilli  are 
of  the  bovine  type. 

Symptoms. — Tuberculosis  is  a  disease  of  so  protean  a  type  that 
its  symptomatology  is  far  too  complicated  to  consider  in  a  work 
so  limited  as  this.  For  the  symptoms  of  the  disease  the  reader  is 
referred  to  any  standard  work  on  practice  or  to  the  special  works 
on  tuberculosis.  It  will  be  sufficient  to  point  out  here  that  acute 
miliary  tuberculosis  at  times  simulates  typhoid  fever,  and  at  others 
cerebrospinal  fever.  From  the  one  it  may  be  distinguished  by  the 
absence  of  the  Widal  reaction  and  the  presence  of  the  tuberculin 
reaction ;  from  the  other,  by  the  presence  of  the  tuberculin  test  and 
the  absence  of  the  diplococci  on  exploratory  spinal  puncture. 

Diagnosis. — If  the  tubercle  bacilli  can  be  detected  in  any  of  the 
bodily  discharges  or  in  an  excised  lesion,  the  diagnosis  is  made. 
For  the  method  of  performing  this,  see  page  875,  Part  III. 

Tuberculin  Reactions. 
Four  methods  of  making  the  tu])erculin  reaction  are  in  use. 
(a)     The  Hypodermic  Method. — This  is  the  oldest,  dating  back 
to  Koch's  early  work.     It  consists  in  giving  hypodermically  1  mg. 


THE   TUBERCULOSIS    GROUP.  345 

of  old  tuberculin  (T.  0.),  whereas  if  the  reaction  is  positive  there 
will  be  a  rise  of  temperature  to  102°  or  104°  inside  of  10  or  12 
hours.  In  case  this  gives  no  reaction,  double  the  amount  is  em- 
ployed 2  or  3  days  later.  If  there  is  no  rise  of  temperature,  the 
patient  may  be  considered  not  to  have  tuberculosis.  By  some 
writers  there  is  thought  to  be  danger  of  relighting  an  old  tubercular 
process  by  this  method. 

(b)  Calmette's  Reaction. — A  drop  of  one-half  or  1  per  cent 
solution  of  tuberculin  is  placed  in  the  conjunctival  sac.  If  tubercu- 
losis is  present  there  will  be  a  reddening  of  the  conjunctiva  within 
12  hours.  This  conjunctival  hyperemia  is  sometimes  too  active,  and 
is  a  reason  why  the  Calmette  method  is  not  safe  for  a  novice. 

(c)  The  Moro  Test. — An  ointment  of  tuberculin  in  lanolin  is 
rubbed  into  the  skin  with  a  spatula.  Hyperemia  of  the  skin  within 
24  hours  is  held  to  indicate  tuberculosis.  A  control  should  be 
made  by  rubbing  a  little  plain,  sterile  lanolin  into  the  skin  at  a 
little  distance,  with  the  same  instrument  for  the  same  time.  This 
test  is  somewhat  unreliable  on  account  of  giving  positive  results  in 
cases  which  never  develop  any  clinical  symptoms.  A  positive  re- 
action is  indicated  by  a  crop  of  small  red  papules  in  24  to  48 
hours. 

(d)  The  von  Pirquet  Percutaneous  Reaction. — The  skin  is 
cleansed  with  ether,  which  is  allowed  to  evaporate.  A  dull  scarifi- 
cator is  employed  sufficiently  to  redden  the  skin  and  divest  it  of 
superficial  epithelium  without  opening  the  blood  or  lymph  chan- 
nels. A  similar  place  is  made  at  a  distance  of  a  couple  of  inches, 
the  thin  hairless  skin  on  the  palmar  surface  of  the  forearm,  being 
the  usual  site  for  this  test.  To  one  scarified  area  is  applied  the 
tuberculin,  and  to  the  other  normal  salt  solution.  They  are  then 
allowed  to  dry  and  a  sterile  plain  gauze  pad  applied.  In  24  hours 
a  positive  reaction  will  be  indicated  by  an  erythematous  blush 
raised  in  the  center  to  a  vivid  red  papule.  The  tuberculin  used  is 
of  the  strength  of  25  per  cent. 

Prophylaxis. — The  means  of  reducing  the  death-rate  and  mor- 
bidity rate  from  tuberculosis  are  several: 

1.  Education. — -The  people  in  general  should  be  informed  by 
every  means  that  tuberculosis  is  a  preventable  and  often  a  curable 
disease. 

2.  Reports. — Tuberculosis  should  be  reported  as  regularly  as 
smallpox.     The  sanitary  authorities  are  then  in  position  to  see 


146  PRACTICAL   SANITATION. 

that  the  general  public  is  protected,  and  that  the  family  of  the 
patient  and  the  patient  himself  are  protected  against  carelessness 
on  his  part. 

3.  Housing. — Improved  housing,  with  due  regard  for  ventila- 
tion and  opportunity  for  cleanliness  always  lower  the  sickness  and 
death-rates  from  tuberculosis. 

4. "  Antispitting  Ordinances. — These  are  referred  to  elsewhere, 
and  are  valuable  only  when  enforced.  The  education  of  the  pa- 
tient is  more  important  ordinarily. 

5.  Segregation  of  the  patients  into  hospitals  and  sanatoria 
where  they  cease  to  be  a  menace  to  the  general  public  and  have  a 
better  chance  to  recover. 

6.  Sputum. — -This  must  be  properly  cared  for  in  destructible 
paper  cups  or  napkins,  which  are  best  burned,  but  may  be  im- 
mersed in  5  per  cent  carbolic  solution  or  2i/^  per  cent  cresol. 
Formaldehyd  and  bichloride  solutions  are  not  reliable,  since  they 
coagulate  the  sputum  without  destroying  the  bacilli  in  the  center 
of  the  lumps. 

7.  Persons  who  are  deemed  in  danger  of  becoming  tuhercular 
should  seek  fresh  air,  good  food,  comfortable  and  suitable  clothing, 
climate  and  season  considered,  and  should  have  every  possible 
bodily  ailment  such  as  catarrh,  adenoids,  enlarged  tonsils  or  any- 
thing which  tends  to  reduce  them  below  par,  attended  to.  Cool 
sponge  baths,  followed  by  brisk  rubbing  with  a  rough  towel,  are 
useful,  but  should  only  be  used  when  a  warm  glowing  reaction  fol- 
lows.    Meals  and  sleep  should  be  regular  and  plentiful. 

Out-of-door  sleeping  is  a  delight  when  one  is  properly  prepared, 
and  should  be  fostered  whenever  possible. 

The  minor  infectious  diseases,  as  well  as  the  more  serious  ones, 
including  scarlet  fever,  measles  and  whooping  cough  should  be 
watched,  should  they  occur  in  a  delicate  child,  and  their  frequently 
disastrous  after-effects  prevented  so  far  as  possible. 

Artificial  Immunity. — Of  late  efforts  are  being  made  toward  the 
establishment  of  active  immunity  against  tuberculosis  by  the  inocu- 
lation of  very  small  numbers  of  bacilli  of  low  virulence.  The  ex- 
perimental work  seems  very  hopeful,  and  was  suggested  by  the  fact 
that  persons  w^ho  have  recovered  from  bone  or  glandular  tubercu- 
losis, which  normally  is  of  low  virulence,  are  very  generally  immune 
thereafter  to  the  disease. 

Isolation. — Under  the  name, of  offering  a  cure,  the  States  and 


THE   TUBERCULOSIS   GROUP.  147 

private  philanthropy  are  providing  isolation  for  the  sick.  While 
the  isolation  is  a  secondary  consideration  to  the  philanthropist,  it 
is  the  primary  consideration  to  the  sanitarian.  There  is  no  ques- 
tion that  it  would  be  best  if  all  tubercular  cases  could  be  treated 
in  these  special  hospitals,  since  they  not  only  present  a  percentage 
of  cures  superior  to  that  possible  in  private  practice,  but  they  edu- 
cate the  patient  so  that  when  he  returns  home  he  is  a  source  of 
information  to  his  neighbors,  and  during  the  time  of  active  progress 
of  the  disease  is  where  his  carelessness  can  be  minimized  and 
checked.  The  most  advanced  ground  yet  taken  by  any  state  is 
the  ^linnesota  requirement  that  all  tuberculous  patients  must  be 
isolated  either  at  home  or  in  a  hospital. 

Disinfection. — It  was  formerly  thought  impossible  to  kill  the 
tubercle  bacilli  with  formaldehyd,  but  if  conditions  are  properly 
looked  after,  and  the  necessary  amount  of  moisture  is  present, 
there  is  no  trouble  in  doing  it.  It  is  well  to  supplement  the  use  of 
formaldehyd  disinfection  (which  should  last  for  at  least  6  hours) 
with  214  per  cent  cresol  solution,  sprayed  or  mopped  on. 

LEPROSY. 

Definition. — ^A  chronic  infectious  disease  caused  by  Bacillus 
leprce  characterized  by  the  presence  of  tubercular  nodules  in  the 
skin  and  mucous  membranes  (tubercular  leprosy)  or  by  changes 
in  the  nerves  (anesthetic  leprosy).  At  first  these  forms  may  be 
separate,  but  ultimately  both  are  combined,  and  in  the  character- 
istic tubercular  form  are  disturbances  of  sensation  (Osier). 

Distribution. — This  disease  has  been  known  for  several  thousand 
years,  and  was  widely  distributed  in  ancient  and  mediaeval  times 
throughout  the  Old  World.  In  the  Sixteenth  Century  it  began  to 
decline,  and  has  disappeared  from  Europe  except  in  certain  locali- 
ties, which  are  in  Scandinavia  and  Russia  on  the  north  and  Spain 
and  Portugal  on  the  south.  In  the  Orient,  particularly  in  China, 
it  is  common.  In  the  United  States  the  number  of  known  lepers 
will  run  to  few  over  100,  who  are  principally  in  State  leprosaria  in 
Massachusetts,  Minnesota,  Louisiana  and  California.  In  the  Insu- 
lar Possessions,  the  great  leper  settlements  at  Molokai  in  the  Ha- 
waiian group  and  Culion  in  the  Calamianes  group  of  the  southern 
Philippines  are  well  known.  Where  the  disease  is  not  kept  under 
control  by  isolation,  it  tends  to  spread. 

Etiology. — The  Bacillus  leprce,  much  resembles  the  tubercle  bacil- 


148  PRACTICAL   SANITATION. 

Ills,  and  is  acid-fast  like  the  latter.  It  is  only  recently  that  it  has 
been  cultivated  successfully  on  artificial  media,  by  first  growing 
the  germ  in  symbiosis  with  species  of  ameba,  and  after  accustoming 
it  to  artificial  conditions,  growing  it  in  pure  culture. 

Modes  of  Infection. — Inoculation. — Inoculation  experiments 
free  from  doubt  are  not  yet  accomplished. 

Heredity. — There  is  no  reason  to  regard  leprosy  as  a  hereditary 
disease.  In  fact  all  the  evidence  and  weight  of  opinion  are 
against  it. 

Contagion. — The  bacilli  are  given  off  in  the  nasal  secretion,  in 
the  saliva,  sputum,  and  the  secretions  from  the  specific  ulcers. 
The  portal  of  infection  is  by  many  authors  believed  to  be  the  nasal 
mucous  membrane,  and  the  means,  inhaled  dust  or  droplets  of  saliva 
containing  the  bacilli  discharged  from  the  mouths  of  lepers  in 
talking  and  coughing.  It  is  also  believed  that  it  may  be  carried 
through  infected  clothing,  a  theory  to  which  the  high  percentage 
of  washerwomen  affected  gives  color.  W.  J.-  Goodhue,  of  JNIolokai 
Leper  Colony,  believes  insects  and  particularly  bedbugs  to  be  the 
usual  carriers,  and  he  has  recovered  B.  lepi'ce  from  their  bodies. 

The  collateral  factors  necessary  for  the  development  of  a  leprous 
infection  are  not  known.  It  has  been  thought  to  be  connected  with 
a  fish  diet  eaten  raw,  but  the  proof  is  by  no  means  definite. 

Pathology. — The  leprous  tubercles  consist  of  granulomatous  tis- 
sue made  up  of  cells  of  various  sizes  in  a  connective  tissue  matrix. 
The  bacilli  in  extraordinary  numbers  lie  partly  between  and  partly 
in  the  cells  (Osier).  These  tubercles  break  down  and  ulcerate  and 
cicatrize,  all  stages  of  development  of  the  tubercles  and  all  stages 
of  ulceration  and  cicatrization  being  seen  at  the  same  time  in  some 
cases.  The  mucous  membranes,  as  that  of  the  larynx  and  the  cornea 
may  become  involved,  causing  loss  of  voice  or  blindness.  There 
may  also  be  extensive  loss  of  tissue  as  whole  fingers  or  toes  or  their 
phalanges.  In  anesthetic  leprosy,  the  characteristic  lesion  is  the 
development  of  the  bacilli  in  the  peripheral  nerves,  causing  a  neu- 
ritis. This  involvement  of  the  nerves  is  responsible  not  only  for 
the  anesthesia  but  for  various  trophic  disturbances. 

Clinical  Forms. — ^Tubercular  Form. — Before  the  appearance  of 
the  tubercles  there  are  areas  of  skin  redness  which  are  often  sharply 
defined  and  tender.  These  spots  in  time  become  pigmented.  Some- 
times this  occurs  without  the  development  of  tubercles,  the  areas 
become  anesthetic,  lose  their  pigment  and  the  skin  becomes  perfectly 


THE   TUBERCULOSIS   GROUP.  149 

white.  It  may  be  a  long  time  after  the  development  of  the  disease 
thus  far  before  it  goes  any  farther,  but  to  one  acquainted  with 
leprosy  the  diagnosis  is  clear. 

As  a  next  step,  the  facial  hair  and  beard  fall  out,  the  mucous 
membrane  of  the  mouth,  throat  and  larynx  becomes  involved,  and 
the  voice  is  husky  or  lost.  Aspiration  pneumonia  may  end  life,  and 
sloughing  of  the  cornea  may  cause  blindness. 

Anesthetic  Form. — Externally,  this  does  not  resemble  the  first- 
described  type  in  the  least.  It  begins  with  pains  in  the  limbs  and 
areas  of  numbness  or  tenderness.  Small  blebs  may  form  as  a  result 
of  trophic  changes.  The  pigmented  spots  described  in  the  preceding 
paragraph  with  their  attendant  involution  are  seen,  but  the  anes- 
thesia may  occur  outside  of  these  spots.  Where  the  nerve  trunks 
can  be  felt  they  are  hard  and  knotted.  Trophic  disturbances  are 
apt  to  be  severe,  and  the  blebs  occurring  in  the  skin  over  these 
disturbed  areas  are  apt  to  slough,  leaving  intractable  ulcers,  and 
sometimes  great  loss  of  substance.  The  loss  of  fingers  and  toes  as  a 
result  of  the  trophic  disturbances  rather  than  the  ulcerations  and 
contractures  are  seen.  As  a  whole  the  disease  is  extremely  chronic, 
Osier  mentioning  a  prominent  clergyman  who  was  a  victim  of  the 
disease  for  30  years  without  its  interfering  with  his  life  and  career 
in  the  slightest. 

Diagnosis. — This  is  made  by  the  appearance  of  the  pigmentations, 
anesthesia,  trophic  disturbances  and  tubercles.  In  case  the  san- 
itarian, inexperienced  in  the  diagnosis  of  the  disease  wishes  help,  he 
can  always  obtain  it  from  the  Public  Health  Service  by  making  his 
need  known  through  the  State  Board  of  Health  or  directly  to  the 
Surgeon-General  of  that  service. 

Microscopic  examination  of  the  secretion  from  ulcers  or  the  nose 
will  enable  an  earlier  diagnosis  in  some  cases. 

rrognosls. — Of  late  years  recoveries  are  being  reported  from  sev- 
eral of  the  leprosaria.  Heretofore  the  disease  has  been  regarded 
as  hopeless. 

Quarantine. — Permanent  isolation.  In  spite  of  the  fact  that 
leprosy  is  not  highly  contagious,  isolation  is  the  only  proved  method 
of  preventing  its  spread. 

Disinfection. — As  for  tuberculosis. 


CHAPTER  XIII. 

THE  TYPHUS  GROUP. 

This  small  group  constitutes,  along  with  Rocky  Mountain  Tick 
Fever,  which  is  omitted  on  account  of  the  small  area  involved  and 
the  prospect  of  its  early  extinction,  and  a  rather  larger  number  of 
tropical  diseases,  a  unit  whose  one  characteristic  is  dissemination 
by  wingless  insects.  Plague,  although  frequently  transmitted  by 
the  flea,  is  also  directly  contagious,  especially  in  the  pneumonic 
forms,  and  is  omitted  for  that  reason. 

TYPHUS  FEVER. 

Synonyms. — Exanthematous  Typhus ;  Putrid  Fever ;  Ship  Fever ; 
Jail  Fever;  Pestilential  Fever;  Petechial  Fever;  Camp  Fever; 
Tabardiilo  (Mexico). 

Distribution. — Endemic  in  Asia  and  Eastern  Europe;  also  in 
Mexico.  Sporadic  in  Western  Europe,  the  United  States  and 
Canada.     Epidemic  in  Eastern  Europe  in  1915. 

Etiology. — Long  thought  to  be  a  filth  disease,  and  this  is  still 
true  in  the  sense  that  it  is  carried  by  lice  both  of  the  head  and 
body.  Rickets  and  Wilder  found  a  bacillus  in  the  blood  but  were 
unable  to  cultivate  it.  Plolz  (April,  1.915)  announced  that  he  had 
cultivated  a  bacillus  which  gives  the  complement  fixation  reaction 
with  blocd  from  recovered  typhus  patients.  This  organism  is  an 
absolute  anaerobe,  which  explains  the  need  of  an  intermediate  insect 
host  and  also  its  long  escape  from  isolation,  since  he  was  the  first 
to  use  anaerobic  methods  of  cultivation.  Vaccines  prepared  from 
it  are  to  be  tried  out  on  a  large  scale  in  Serbia,  and  the  question 
of  its  i)athog(^nicity  will  doulitless  be  scon  authoritatively  settled. 

Pathology. — Nothing  distinctive  is  found.  The  spleen  is  en- 
larged and  the  liver  and  kidneys  are  the  seat  of  cloudy  swelling. 
Granular  degeneration  of  other  organs  including  the  heart  may 
be  present.  The  blood  is  dark  and  liquid  and  rigor  mortis  may  be 
delayed.  The  peculiar  petechial  eruption  remains  after  death,  and 
there  may  be  gangrenous  bed-sores.  Hypostatic  congestion  of  the 
lungs  is  often  found. 

1.50 


THE    TYPHUS    GROUP.  151 

Incubation. — 12  days,  approximately. 

Predisposing  Factors. — Fatigue;  poor  nourishment. 

Prodromes. — None,  onset  sudden. 

Symptoms. — Chill;  headache;  great  pain  in  back  and  muscles; 
temperature  rising  rapidly  to  103°  and  106°.  Pulse  at  first  full 
and  strong,  afterwards  rising  to  120  and  becoming  weaker.  Con- 
junctivae congested,  face  dusky,  expression  dull,  low  muttering  de- 
lirium. Tongue  dry  and  coated.  Bowels  constipated.  Eruption 
comes  out  on  third  to  fifth  day,  and  is  of  two  kinds,  petechial  and 
mottled.  The  first  variety  is  not  unlike  that  of  typhoid,  but  is 
darker  and  disappears  less  easily  on  pressure;  when  well  estab- 
lished it  disappears  not  at  all.  AVhen  the  stage  of  non-disappear- 
ance is  reached,  the  blood  is  already  outside  the  vessels.  All  stages 
of  the  eruption  may  be  seen  at  one  time  in  the  same  case. 

With  the  beginning  of  the  second  week  all  the  symptoms  deepen. 
The  tongue  becomes  fissured,  there  is  sordes  on  the  teeth,  the  stupor 
deepens,  there  is  coma  vigil,  in  which  the  eyes  are  wide  open  though 
the  patient  is  unconscious,  there  are  nystagmus  and  twitching  of 
the  tendons.  A  peculiar  odor,  disagreeable  and  ammoniacal,  and 
thought  by  some  to  be  characteristic  is  present. 

Albuminuria  and  retention  of  urine  are  often  seen.  Bronchial 
catarrh,  cough,  broncho-pneumonia  and  gangrene  of  the  lungs 
may  complicate  matters.     Gangrene  of  the  extremities  may  occur. 

Diagnosis. — Early  high  temperature;  initial  chill  (frec[uently)  ; 
petechise  dark,  not  much  disappearing  on  pressure;  great  prostra- 
tion ;  much  pain ;  morning  remissions  slight  or  none ;  serum  reac- 
tions negative  to  typhoid  and  paratyphoid ;  no  cocci  in  spinal  fluid ; 
ambulant  cases  sometimes  met. 

Differentiation. — Differentiate  from  hemorrhagic  smallpox; 
cerebrospinal  meningitis;  malignant  measles;  bubonic  plague. 

Termination. — In  fatal  eases  from  exhaustion,  hypostatic  pneu- 
monia, or  gangrene  of  the  lungs ;  in  non-fatal  cases  by  crisis  at  the 
end  of  the  second  week.  Convalescence  often  slow  but  relapses 
are  rare. 

Prognosis. — The  mortality  is  high,  from  12  to  50  per  cent  in 
different  epidemics,  averaging  about  20  per  cent. 

Quarantine  for  Sick. — Strict,  until  convalescence  is  thoroughly 
established,  4  weeks  at  least.  Treatment  should  be  carried  on  in 
tents  or  open  pavilions  for  the  safety  of  the  attendants  as  well  as 
for  the  good  of  the  sick. 


152  PRACTICAL   SANITATION. 

Quarantine  for  Contacts. — 14  days.     Strict. 

Individual  Prophylaxis. — Personal  cleanliness;  avoid  all  unnec- 
essary contact  with  the  sick ;  rubber  gloves  when  handling  patient ; 
avoid  fatigiie.  Use  coal  oil  freely  on  person  and  clothing  during 
any  exposure,  as  an  insecticide. 

Community  Prophylaxis. — Clean  up  and  whitewash  all  dark 
filth}'-  places;  burn  sulphur  freely  in  such  localities,  or  if  unin- 
habited use  first  hydrocyanic  acid  to  kill  all  animal  life;  rigidly 
quarantine  all  suspects,  preferably  in  tents  in  an  isolation  camp. 
Use  liquid  disinfectants  such  as  phenol  and  cresol  derivatives 
freely  in  all  suspicious  places  and  on  all  sick  room  waste  and  ex- 
creta; such  things  as  can  be  destroyed  by  fire  should  be  burned. 
Use  steam  disinfection  to  kill  lice  in  clothing,  and  mercurial  oint- 
ment on  any  part  of  body  showing  "nits." 

Disinfection. — Sulphur,  formaldehyd  with  camphor  for  inhabited 
places;  if  the  building  can  be  entirely  emptied  of  people,  first  use 
hydrocyanic  gas.  {Caution.)  Liquid  disinfection,  steam,  boiling 
or  burning  for  contaminated  articles. 

Atypical  Typhus. 

A  mild  atypical  fever  known  as  "Brill's  Disease"  has  been 
rather  widely  encountered  in  the  United  States,  and  is  shown  by 
inoculation  experiments  on  monkeys  to  be  identical  with  typhus, 
an  attack  of  either  disease  immunizing  against  the  other. 

RELAPSING  (SPIRILLUM)  FEVER. 

Synonyms. — Febris  recurrens;  Famine  Fever;  Seven  Day  Fever; 
Typhus  icterodes. 

Definition. — Relapsing  fever  is  an  acute  infectious  disease  char- 
acterized by  two  or  more  total  remissions,  produced  by  infection 
with  the  Spirochcete  ohermeieri. 

Distribution. — Endemic  in  Europe  and  Asia;  rarely  in  small 
epidemics  in  United  States. 

Etiology. — The  Spirochajte  (Spirillum)  obermeieri  is  a  proto- 
zoon  21/2  to  8  mi.  in  length  and  2  to  2%  mi.  in  greatest  width  of 
spiral.  It  is  found  floating  free  in  the  blood  during  the  paroxysms 
but  disappears  during  the  intervals  between,  while  small  glistening 
spherules  supposed  to  be  spores  take  their  place.  Relapsing  fever 
is  a  disease  of  overcrowding  and  misery,  rarely  attacking  the  well- 
to-do.     All  ages,  both  sexes  and  all  nationalities  are  attacked  and 


THE   TYPHUS   GROUP.  153 

season  is  without  influence.  It  is  highly  infectious,  and  is  possibly 
transmitted  by  droplet  infection,  but  more  probably  by  the  bites 
of  insects,  such  as  bedbugs  and  lice. 

Pathology. — The  only  constant  gross  change  to  be  found  is  a 
splenic  enlargement.  Otherwise  the  conditions  somewhat  resemble 
typhus. 

Predisposing  Factors. — Poor  food  and  fatigue. 

Incubation. — 2  to  14  days. 

Prodromes. — Rarely  malaise  and  loss  of  appetite.     Usually  none. 

Symptoms. — Invasion  abrupt,  with  chill,  fever,  intense  pain  in 
back  and  limbs,  with  dizziness.  Temperature  quickly  to  104° ; 
pulse  on  second  day  to  140,  150,  or  160;  there  may  be  nausea, 
vomiting,  and  delirium,  and  in  children,  convulsions;  tongue  re- 
mains moist;  there  is  jaundice  on  third  or  fourth  day  in  6  to  20 
per  cent  of  all  cases.  Sweating  and  sudamina  may  be  present,  and 
sometimes  petechise  or  herpes,  or  a  mottling  like  that  of  typhus, 
but  disappearing  on  pressure.  Abdominal  tenderness  is  sometimes 
seen,  and  the  liver  may  be  enlarged. 

Termination  is  by  crisis  on  the  sixth  or  seventh  day,  the  tem- 
perature going  to  normal  or  below.  Crisis  may  be  preceded  by 
diarrhea,  nose-bleed  or  the  menstrual  flow. 

Relapse  takes  place  in  about  one  week ;  the  paroxysm  is  repeated, 
and  a  crisis  is  reached  at  a  somewhat  shorter  interval.  This  may 
be  repeated  as  often  as  five  or  six  times,  the  seizures  becoming 
shorter.     Convalescence  is  usually  rapid,  but  may  be  long. 

Complications. — Bronchitis;  nephritis;  rupture  of  the  spleen 
from  over-distension;  pneumonia;  abortion  in  pregnant  women 
with  death  of  the  fetus  usually  occurs.  Toxic  paralysis  and  oph- 
thalmia accompany  some  epidemics. 

Differentiation. — Differentiate  from  typhus ;  smallpox ;  influenza ; 
dengue ;  malaria. 

Prognosis. — In  Great  Britain  and  Ireland,  4.3  per  cent  is  the 
average  mortality  for  several  years.  In  Bombay,  an  epidemic 
showed  a  little  over  18  per  cent  and  the  one  in  Philadelphia,  14  per 
cent. 

Quarantine. — Should  continue  till  the  spirilla  are  absent  from 
the  blood  for  several  days  after  the  time  for  the  relapse  to  take 
place.  Contacts  should  be  held  under  observation  but  not  neces- 
sarily quarantined  till  14  days  have  expired. 

Prophylaxis. — Both  individual  and  community  are  secured  by 


154  PRACTICAL   SANITATION, 

a  general  clean-up  campaign,  with  feeding  of  the  destitute,  and 
the  destruction  of  bedbugs,  lice  and  other  predacious  insects,  to- 
gether with  care  to  avoid  unnecessary  contact  with  the  patient  by 
physicians  and  nurses. 

Disinfection. — Preferably  by  strong  bichloride  or  cresol  com- 
pounds applied  to  all  cracks  and  crannies  with  a  mop,  and  weaker 
solutions  applied  to  the  walls  and  floors.  Sulphur  or  hydrocyanic 
acid  fumigation  to  destroy  insects  may  be  used  if  the  house  can  be 
emptied  temporarily. 

TROPICAL  SPLENOMEGALY. 

Synonyms. — Tropical  Cachexia  ;  Piroplasmosis ;  Leishmanniasis ; 
Dum-Dum  Fever;  Kala  Azar. 

Definition. — A  chronic  disease  of  tropical  and  sub-tropical  coun- 
tries, characterized  by  enlarged  spleen,  anemia,  irregular  fever  of 
a  remittent  type,  due  to  infection  with  a  protozoon,  Leishmania 
dorovani. 

Distribution. — This  disease  is  found  in  India,  Assam,  China, 
Ceylon,  Egypt,  the  Mediterranean  coast  of  Africa,  and  Greece. 

The  Parasite. — This  was  discovered  first  by  Leishman  in  1900, 
and  shortly  afterward  the  subject  was  taken  up  by  a  number  of 
workers,  whose  work  has  been  confirmatory.  The  organism  is 
found  most  abundantly  in  the  spleen,  the  liver,  mesenteric  and 
other  lymphatic  glands,  intestinal  and  skin  ulcers,  but  not  in  the 
peripheral  blood  in  chronic  cases.  It  is  variously  shaped,  being 
oat-shaped,  oval  or  circular,  has  a  spherical  nucleus  close  to  the 
capsule  with  a  short  rod-shaped  body  on  the  opposite  side.  They 
may  be  closely  applied  to  each  other  in  pairs  or  groups  or  rosettes. 

While  the  Leishmania  h  most  readily  found  in  the  splenic  blood, 
splenic  puncture  is  not  safe  for  the  purpose  of  obtaining  it,  since 
fatal  hemorrhage  or  rupture  of  the  spleen  may  be  precipitated 
by  the  ordinarily  trifling  operation.  On  the  contrary,  a  diagnosis 
cannot  be  made  without  the  discovery  of  the  parasite.  The  best 
and  safest  way  of  doing  this  is  to  dissect  out  under  local  anesthesia, 
one  of  the  superficial  cervical  or  inguinal  lymph-nodes,  cut  it, 
smear  the  cut  surface  on  a  slide  and  stain  with  the  Wright,  Leish- 
man or  Oiemsa  stain  (Cochran). 

Symptoms. — Leishman 's  description  of  the  symptoms  is  as  fol- 
lows: "Splenic  and  hepatic  enlargement — the  former  being  ap- 
parently constant,  while  the  latter  is  common  but  not  invariable. 


THE    TYPHUS   GROUP.  155 

A  peculiar  earthy  pallor  of  the  skin,  and,  in  the  advanced  stages, 
an  intense  degree  of  emaciation  and  muscular  atrophy.  A  long- 
continued,  irregularly  remittent  fever  of  no  definite  type,  lasting 
frequently  for  months,  with  or  without  remissions.  Hemorrhages, 
such  as  epistaxis,  bleeding  from  the  gums,  subcutaneous  hemor- 
rhages or  purpuric  eruptions.  Transitory  edemas  of  various  re- 
gions or  of  the  limbs."  The  red  cells,  notwithstanding  the  grave 
anemia  are  not  usually  reduced  below  2,000,000  per  C.  M.  The 
white  cells  are  also  reduced  in  number,  while  a  percentage  count 
shows  that  the  lymphocytes  and  large  mononuclear  cells  are  rel- 
atively increased. 

Prognosis. — Almost  uniformly  fatal  to  dark-skinned  races.  Cau- 
casians are  not  often  attacked. 

Mode  of  Infection. — By  the  bite  of  the  common  bedbug  (Patton) . 

Prophylaxis. — The  sick  must  be  isolated  away  from  bedbugs. 
The  parasite  is  recently  reported  as  destroyed  by  the  newer  organic 
arsenic  compounds,  as  atoxyl  and  salvarsan.  These  should  be  em- 
ployed not  only  as  a  therapeutic  measure,  but  also  for  the  purpose 
of  destroying  a  focus  of  infection.  Lastly,  a  determined  campaign 
against  bedbugs  must  be  carried  out. 


CHAPTER  XIV. 

THE  MENINGITIS  GROUP. 

This  group  consists  of  the  two  diseases,  cerebrospinal  meningitis 
and  acute  poliomyelitis.  Both  affect  the  central  nervous  system, 
and  in  both  the  portal  of  infection  is  probably  nearly  or  quite  in- 
variably through  the  nasal  passages.  Both  are  highly  but  irreg- 
ularly infectious,  and  the  same  measures  available  against  the 
one  are  almost  equally  valuable  against  the  other,  with  the  excep- 
tion that  we  do  not  yet  possess  a  serum  against  acute  poliomyelitis. 

ACUTE  POLIOMYELITIS. 

Synonyms. — Epidemic  Poliomyelitis;  Acute  Anterior  Poliomye- 
litis; Infantile  Paralysis;  Epidemic  Paralysis;  "Polio." 

Definition. — An  acute  infectious  disease  of  protean  aspects,  in- 
volving the  central  nervous  system,  affecting  both  children  and 
adults  but  chiefly  children  before  the  age  of  the  second  denti- 
tion. 

Etiology. — The  etiology  of  this  disease  is  but  little  understood. 
It  is  known  that  the  virus  is  still  active  after  passing  through  a 
porcelain  filter,  as  are  the  poisons  of  foot-and-mouth  disease,  yellow 
fever  and  a  few  others.  It  remains  active  in  glycerine  for  months, 
like  that  of  vaccinia,  and  resists  drying  over  caustic  potash  for  a 
long  time.  It  is  known  to  be  present  in  the  nasal  secretions,  like 
that  of  cerebrospinal  fever,  is  thought  to  be  transmitted  by  dust 
and  by  some  insect,  probably  the  fly,  on  account  of  its  seasonal 
incidence  being  chiefly  in  the  warm  months.  So  far  virulent  cul- 
tures have  not  been  grown  outside  the  body.  Monkeys  are  sus- 
ceptible to  the  disease,  and  most  of  the  experimentation  on  animals 
has  been  done  with  them.  There  is  ground  for  hope  that  a  method 
of  immunization' may  soon  be  found,  although  as  yet  none  is  known. 

The  sanitarian  must  be  on  his  guard  against  accepting  conclu- 
sions concerning  the  etiology  and  symptomatology  from  text-books 

156 


THE  MENINGITIS  GROUP.  157 

more  than  a  year  or  two  old,  but  should  strive  to  keep  informed  on 
the  subject  from  periodical  literature.  The  literature  of  the  sub- 
ject is  voluminous  and  most  of  it  recent,  and  text-book  articles  are 
apt  to  begin  to  be  obsolete  before  they  are  off  the  press. 

Prevalence. — For  the  decade  ending  in  1904,  157  cases  were  re- 
ported in  the  literature,  a  figure  probably  much  less  than  the  true 
number,  since  it  was  not  then  reportable  as  an  infectious  disease. 
In  the  one  year  1910,  8,700  cases  were  reported  and  the  sanitary 
authorities  of  practically  every  State  were  engaged  in  a  campaign 
to  limit  its  ravages.  Mortality  reports  are  not  available,  but  the 
State  Board  of  Health  of  Indiana  reports  60  deaths  out  of  a  total 
estimated  morbidity  of  300,  both  figures  probably  being  too  low, 
since  fatal  cases  are  apt  to  be  reported  as  some  form  of  meningitis, 
and  there  are  many  abortive  or  missed  cases.  As  in  other  diseases, 
these  mixed  cases  are  the  most  difficult  to  control,  and  with  "car- 
riers" who  can  be  suspected  but  not  demonstrated  as  yet,  are 
probably  the  most  important  factors  in  the  spread  of  the  disease. 

Pathology. — At  present  it  is  believed  that  the  first  point  of 
attack  of  the  infection  is  the  pia  mater,  usually  beginning  in  the 
lumbar  region  and  extending  afterward  to  the  cord  and  brain,  or 
aborting  without  further  extension,  or  extending  to  the  dura  mater, 
or  involving  many  nerves  without  necessarily  involving  the  central 
nervous  system  to  any  great  degree.  The  destruction  of  cells  in 
the  gray  matter  of  the  cord,  medulla  or  l)rain  with  its  consequent 
paralyses  is  7iot  the  disease,  hut  the  end  result,  and  is  comparable  to 
other  permanent  toxic  paralyses,  as  for  instance  the  paralysis  of 
the  optic  nerve  due  to  wood-alcohol  poisoning. 

Prodromes. — Slight  or  pronounced  fever,  pain  in  back  and  limbs, 
and  slight  catarrhal  symptoms;  nausea  and  vomiting.  So  far  the 
symptoms  are  in  no  wise  characteristic,  but  if  to  them  is  added 
profuse  siveating,  suspicion  should  be  at  once  aroused,  and  the 
exhibition  of  hexamethylenamine  should  be  begun  at  once,  since 
experimental  evidence  has  shown  that  this  drug  markedly  modifies 
the  toxicity  and  communicability  of  the  disease. 

Types.— The  further  progress  of  the  disease  is  classified  by  Wick- 
man  as  follows: 

I.     The  spinal  poliomyelitic  type. 
II.     The  type  of  ascending  or  descending  paralysis,  simulating 

Landry's  paralysis. 
III.     The  bulbar  or  pontine  type. 


158  PRACTICAIv   SANITATION. 

IV.  The  encephalitic  type. 

V.  The  ataxic  type. 

VI.  The  polyneuritic  type. 

VII.  The  meningeal  type. 

VIII.  Abortive  types. 

Symptoms. — The  spinal  poliomyelitic  type  is  the  one  described  in 
the  text-books  of  more  than  five  years  ago.  After  the  premonitory 
symptoms  described  above,  which  may  have  passed  unnoticed,  there 
is  a  rapid  development  of  a  paralysis  involving  one  or  more  groups 
of  muscles,  which  may  remain  permanent,  but  ordinarily  recedes 
until  only  one  or  two  groups  are  permanently  paralyzed  with  a 
flaccid  paralysis.  It  may,  however,  involve  practically  the  whole 
body  below  the  neck.  The  bulbar  type  involves  the  cranial  nerves, 
with  or  without  the  spinal  nerve-centers. 

The  other  types  simulate  more  or  less  closely  the  types  of  paraly- 
sis whose  names  are  given  to  them,  and  approximate  descriptions 
will  be  found  in  any  text-book  on  nervous  diseases,  lack  of  space 
forbidding  their  introduction  here. 

The  abortive  types  are  the  most  baffling  and  are  most  apt  to  be 
overlooked  until  the  general  profession  is  much  better  informed 
on  the  subject  than  it  is  at  present.  In  these  the  invasion  symp- 
toms are  present,  but  the  later  paralyses  do  not  develop.  Instead 
there  may  be  severe  nausea  and  vomiting  or  diarrhea  or  all  of  these, 
apparently  pointing  to  the  elimination  of  the  poison  by  the  gastro- 
intestinal tract  instead  of  its  fixation  in  the  central  nervous  system, 
precisely  as  the  well-known  toxins  of  diphtheria  are  sometimes  elimi- 
nated without  trouble  and  sometimes  cause  paralysis. 

Some  cases  of  the  abortive  type  present  symptoms  of  a  more  or 
less  severe  general  infection,  others  of  a  meningeal  irritation,  and 
still  others  much  pain  and  hyperesthesia  such  as  are  seen  in  influ- 
enza. 

Diagnosis. — As  yet  impossible  before  the  development  of  the 
paralysis  in  sporadic  cases.  In  epidemics  the  abortive  types  are 
more  apt  to  be  recognized.  In  the  meningeal  type,  the  presence 
of  a  sterile  spinal  fluid,  under  pressure,  will  differentiate  it  from 
meningitis,  but  except  in  these  cases  spinal  puncture  is  not  to  be 
recommended. 

Prognosis. — The  mortality  varies  from  3  to  15  per  cent  with  an 
average  of  about  7  per  cent.  The  majority  of  the  abortive  cases 
make  complete  recovery.     The  ascending,  bulbar  and  meningitic 


THE  MENINGITIS  GROUP.  159 

cases  present  the  worst  prognosis  as  to  life,  but  even  these  rarely 
die  after  the  seventh  day. 

Prophylaxis. — Isolation  of  the  patient  except  for  the  necessary 
attendance.  Screening  from  flies.  All  utensils  coming  in  contact 
with  the  patient's  mouth  must  be  immediately  disinfected.  All 
nasal  or  buccal  secretions  must  be  immediately  destroyed  by  burn- 
ing or  by  efficient  chemical  germicides.  The  physical  condition  of 
other  members  of  the  family  must  be  carefully  looked  after.  The 
case  must  be  reported  at  once  to  the  authorities,  who  will  see  that 
the  latest  information  is  placed  in  the  hands  of  the  physician. 
Both  the  profession  and  public  must  be  educated  to  a  knowledge  of 
the  dangerous  infectiousness  of  the  disease. 

Quarantine. — At  least  28  days;  modified. 

Disinfection. — Terminal  disinfection  with  formaldehyd  is  ad- 
visable, although  not  everywhere  required. 

CEREBROSPINAL  FEVER. 

Synonyms. — Spinal  IMeningitis;  Cerebrospinal  Meningitis; 
' '  Spotted  Fever ' ' ;  Malignant  Purpuric  Fever ;  Petechial  Fever. 

Definition. — An  infectious  disease,  occurring  sporadically  and  in 
epidemics,  caused  by  the  Diplococcus  intracellularis,  characterized 
by  inflammation  of  the  cerebrospinal  meninges  and  a  clinical  course 
of  great  irregularity   (Osier). 

Etiology. — Cerebrospinal  fever  occurs  both  in  sporadic  and  epi- 
demic forms,  the  epidemics  usually  being  localized  and  affecting 
country  districts  ordinarily  more  in  proportion  than  cities.  Min- 
ing districts  and  seaports  have  suffered  most  severely.  It  is  a 
military  disease  of  importance,  and  is  always  to  be  reckoned  with 
whenever  recruits  are  concentrated  for  the  first  time  in  camps  or 
barracks. 

The  greatest  incidence  occurs  in  childhood  and  young  adult  life, 
the  disease  decreasing  in  frequency  from  the  first  years  of  life, 
about  65  per  cent  according  to  the  United  States  Census  Report 
for  1904  occurring  under  the  age  of  5  years.  Fatigue,  misery,  and 
poor  nutrition  are  important  factors  in  aiding  the  dissemination  of 
this  disease. 

According  to  Flexner's  very  careful  experimental  work  on  apes 
and  monkeys,  the  disease  is  most  probably  contracted  through  in- 
fection of  the  nasal  mucous  membrane  by  the  diplococcus.  The 
organism  may  be  recovered  from  the  nasal  secretion  of  patients 


160  PRACTICAL   SANITATION. 

sick  of  the  disease  and  also  from  that  of  "carriers"  who  may  or 
may  not  be  immune  to  the  disease.  When  the  intimate  connection 
and  short  route  existing  between  the  mucous  membrane  of  the  nose 
and  the  cerebral  meninges  is  considered,  it  is  easy  to  see  the  ease 
with  which  infection  of  susceptible  persons  can  occur. 

The  Diplococcus  Intracellularis. — This  organism  is  charac- 
terized by  the  great  regularity  with  which  it  is  found  inside  the 
polymorphonuclear  leucocytes.  Superficially  it  resembles  the 
D.  lanceolaUis  (Pneumococcus)  and  is  akin  to  it  in  being  able  to 
cause  both  pneumonia  and  meningitis,  but  is  quite  different  from 
it  in  cultural  characteristics.  It  is  found,  as  before  stated,  in  the 
nasal  secretion  of  the  sick  and  of  healthy  contacts,  in  the  cerebro- 
spinal fluid  regularly,  and  sometimes  in  the  lungs ;  it  has  also  been 
cultivated  from  pus,  the  joints,  from  pneumonic  areas  in  the  lungs, 
and  with  comparative  ease  from  the  blood. 

Pathology. — In  malignant  cases  death  may  occur  before  any 
characteristic  changes  have  taken  place,  the  brain  and  spinal  cord 
showing  only  intense  congestion.  There  is  intense  congestion  of 
the  pia-arachnoid.  The  exudate  is  of  pus  with  fibrin  flakes,  most 
prominent  at  the  base  of  the  brain  where  the  meninges  may  be 
greatly  thickened  and  plastered  over  with  it.  The  whole  brain 
cortex  may  be  covered  with  this  type  of  exudate.  Sometimes  a  fluid 
resembling  pus  is  found  between  the  dura  and  pia  mater.  The 
cord  is  always  involved  with  the  brain,  and  the  exudate  is  more 
marked  on  the  posterior  surface  and  in  the  dorsal  and  lumbar  por- 
tions rather  than  the  cervical. 

In  the  more  chronic  cases,  the  meninges  are  generally  thickened 
and  yellow  patishes  here  and  there  mark  former  sites  of  the  exudate. 
In  the  acute  cases,  the  ventricles  are  dilated  and  contain  a  turbid 
fluid  or  in  the  posterior  horns,  pure  pus.  In  the  chronic  cases  the 
dilatation  may  be  very  great.  The  brain  substance  has  a  pink 
tinge  and  is  softer  than  usual.  Spots  of  hemorrhage  and  of  inflam- 
mation of  the  brain  substance  may  be  found.  The  cranial  nerves 
are  frequently  involved,  especially  the  second,  fifth,  seventh,  and 
eighth.     The  spinal  nerve  roots  are  often  surrounded  by  exudate. 

Under  the  microscope  the  exudate  consists  chiefly  of  polymorpho- 
nuclear white  cells  closely  packed  in  threads  of  fibrin.  Minute 
abscesses  or  hemorrhages  may  be  seen  sometimes.  The  cells  of  the 
nerve-sheaths  are  swollen  and  show  large,  clear,  vesicular  nuclei. 
The  ganglion  cells  are  less  changed.     Diplococci  are  found  in  vari- 


THE   MENINGITIS  GROUP.  161 

able  numbers  in  the  exudate,  but  are  more  numerous  in  that  taken 
from  the  brain. 

Other  organs  than  the  brain  and  cord  show  no  constant  charac- 
teristic changes,  the  organ  most  commonly  involved  aside  from 
these  being  the  lung,  with  a  resultant  pneumonia  or  pleurisy. 
Endocarditis  is  sometimes  seen. 

Symptoms. — Malignant  Form. — This  is  of  the  fulminant  or  apo- 
plectic type  and  shows  a  sudden  onset,  with  violent  chills,  headache, 
somnolence,  muscular  spasms,  great  depression,  moderate  fever,  and 
feeble  pulse,  which  is  often  slowed  to  50  or  60  per  minute.  There 
is  usually  a  purpuric  rash.  The  whole  march  of  the  disease  from 
apparently  perfect  health  to  a  fatal  termination  occupies  only  a 
little  over  24  hours  at  most,  and  recorded  cases  have  shown  a 
duration  of  as  little  as  5  hours. 

Ordinary  Form. — The  length  of  the  incubation  period  is  not 
known,  and  the  disease  usually  sets  in  suddenly.  Headache,  pain 
in  the  back,  vomiting  and  loss  of  appetite  sometimes  foreshadow  the 
coming  attack.  The  temperature  goes  up  to  101°  or  102°.  The 
pulse  is  full  and  strong.  An  early  and  important  symptom  is  stiff- 
ness of  the  neck  muscles,  which  are  quite  painful  on  movement. 
The  headache  becomes  more  severe,  the  eyes  are  sensitive  to  light, 
and  any  noise  is  intensely  annoying.  Children  become  irritable 
and  restless.  In  severe  cases  the  contraction  of  the  neck  muscles 
sets  in  early  and  the  head  draws  back.  The  back  may  be  rigidly 
straight  or  bent  back.  Muscular  pains  throughout  the  body  are 
severe.  The  muscles  may  be  tremulous  or  there  may  be  tonic  or 
clonic  spasms  of  arms  or  legs.  With  the  rigidity  of  the  trunk 
muscles  there  may  be  such  extreme  contraction  of  the  neck  muscles 
that  the  back  of  the  head  lies  between  the  shoulder-blades.  Gen- 
eral convulsions  are  not  common  except  in  childhood.  Strabismus 
is  a  common  symptom.  Paralysis  of  eye  and  face  muscles  is  not 
uncommon,  though  paralysis  of  trunk  muscles  is  rare. 

Of  sensory  symptoms,  headache  is  the  most  persistent  and  con- 
stant. It  is  chiefly  in  the  back  of  the  head,  radiating  into  the  neck 
and  back.  The  spine  may  be  extremely  sensitive,  and  general 
hyperesthesia  may  exist. 

Delirium  of  a  wild  and  maniacal  type  may  occur,  but  is  not 
usually  so  pronounced.  Marked  erotic  symptoms  are  sometimes 
seen  at  the  beginning.  In  a  few  days  the  delirium,  with  the  ad- 
vance of  the  exudate,  gives  way  to  stupor  and  this  again  to  coma. 


162  PRACTICAL   SANITATION. 

The  temperature  is  irregular  and  variable.  There  are  frequent 
remissions,  and  no  constant  or  regular  curve  of  temperature  can 
be  laid  out.  Sometimes  the  fever  is  slight  or  wanting.  In  other 
cases  it  may  reach  105°  or  before  death  108°  (Osier).  A  personal 
case  showed  110°  immediatelj^  before  death. 

The  pulse  in  children  may  be  very  rapid ;  in  adults  it  is  generally 
full  and  strong.  It  rnay  be  slowed  to  50  or  60  in  the  minute. 
Cheyne-Stokes  respiration  and  sighing  are  sometimes  seen,  but  in 
the  absence  of  pneumonia,  respiration  is  not  usually  much  quickened. 

The  skin  manifestations  are  important.  Herpes  is  almost  as 
constant  as  in  pneumonia.  The  petechial  rash  which  has  given 
the  disease  the  name  of  spotted  fever,  is  not  always  present,  varying 
in  frequency  in  different  epidemics.  In  35  to  40  per  cent  of  the 
cases  there  is  none  or  it  is  negligible ;  in  other  cases  the  whole  body 
may  be  covered.  An  erythema  or  dusky  mottling  is  sometimes 
present,  or  there  may  be  rose  spots  like  those  of  typhoid.  Urticaria, 
erythema  nodosum,  ecthyma,  pemphigus  and  gangrene  of  the  skin 
are  rarities. 

The  leucocytosis  is  massive,  from  25,000  to  40,000  per  C,  M.  It 
persists  as  long  as  the  disease  lasts,  no  matter  how  chronic  it  may 
become. 

The  vomiting  noted  as  an  initial  symptom  sometimes  persists, 
and  may  be  the  most  annoying  feature  of  the  illness.  Ordinarily 
it  soon  subsides  and  gives  no  trouble.  The  bowels  are  usually  con- 
stipated, and  the  reverse  condition  is  rare.  The  spleen  is  rather 
constantly  enlarged. 

The  urine  may  be  albuminous  or  increased  in  quantity.  Sugar 
is  sometimes  noted,  and  in  malignant  types,  blood. 

Course. — The  course  of  the  disease  varies  between  a  few  hours 
and  several  months.  More  than  half  of  the  deaths  occur  in  the 
first  5  days.  In  favorable  cases  the  symptoms  after  persisting  for 
5  or  6  days  gradually  lessen,  the  spasm  improving,  the  fever  drop- 
pining  and  the  delirium  waning.  Sudden  drops  in  the  temperature 
are  of  grave  import.  Convalescence  is  tedious  and  protracted. 
Complications  and  sequelie  are  frequent  and  troublesome. 

Abortive  Type. — The  attack  sets  in  with  great  severity,  but  the 
symptoms  ameliorate  after  a  day  or  two,  and  improvement  is  rapid. 
It  is  not  to  be  confounded  with  ambulant  mild  cases,  where  the 
difference  is  of  degree  and  not  of  time,  which  latter  cases  are  ordi- 


THE  MENINGITIS  GROUP.  163 

narily  only  to  be  recognized  as  meningitis  in  the  presence  of  an 
epidemic. 

Intermittent  Type. — This  has  been  observed  in  many  epidemics 
and  shows  a  temperature  curve  like  that  of  malarial  intermittent 
or  remittent  fever,  with  daily  or  tertian  exacerbations,  or  more 
frequently  like  the  intermissions  or  remissions  of  pyemia. 

Chronic  Form. — This  form  is  fairly  frequent.  The  attack  is 
protracted  from  2  to  6  months,  and  there  may  be  the  most  pro- 
nounced wasting  of  the  body.  In  a  portion  of  these  cases  chronic 
hydrocephalus  or  brain  abscess  is  probably  present.  It  differs  dis- 
tinctly from  the  intermittent  type. 

Complications. — Pneumonia  has  already  been  mentioned  as  a 
common  associate  of  cerebrospinal  fever,  and  in  some  cases  it  is 
difficult  or  impossible  to  say  which  is  the  primary  condition.  In 
some  cases  true  pneumonia  caused  by  the  pneumococcus  is  asso- 
ciated with  this  disease;  in  others,  they  are  two  phases  of  one 
infection. 

Joint  inflammations  are  common  in  some  epidemics. 

Pleurisy,  pericarditis,  and  parotitis  are  not  rare. 

Paralysis  temporary  or  permanent,  of  various  cranial  nerves  or 
groups  of  muscles  occurs.  This  may  be  due  at  times  to  an  accom- 
panying peripheral  neuritis. 

Headache  may  be  persistent  for  years  after  an  attack. 

Chronic  hydrocephalus  sometimes  occurs  in  children. 

Aphasia  and  feehle-mind  are  occasionally  observed. 

Special  Senses. — Eye. — Inflammation  of  the  optic  nerve  may  be 
caused  by  involvement  in  the  exudate  at  the  base  of  the  brain. 
One  series  of  40  cases  showed  6  instances  of  involvement  of  the 
optic  nerve.  The  inflammation  may  also  extend  into  the  ball, 
causing  purulent  irido-choroiditis  and  loss  of  the  eye  by  bursting. 
When  the  fifth  nerve  is  involved,  corneal  inflammation  and  ulcer- 
ation frequently  follow. 

Ear. — Labyrinthine  involvement  often  causes  deafness.  Middle 
ear  and  mastoid  abscesses  occur  by  direct  extension.  55  per  cent 
of  a  series  of  recovered  cases  were  deaf.  It  is  suggested  that 
the  abortive  form  may  be  responsible  for  much  early  acquired  deaf- 
ness of  unknown  origin. 

Nose. — Striimpell  suggests  that  the  frequently  observed  coryza 
present  at  the  beginning  of  the  disease  may  be  the  first  stage  of 


164  PRACTICAL   SANITATION. 

the  infection.  This  is  also  borne  out  by  Flexner's  experiments 
already  noticed. 

Diagnosis. — Stokes's  maxim  must  be  borne  in  mind,  that  "there 
is  no  single  nervous  symptom  which  may  not  and  does  not  occur 
independently  of  any  appreciable  lesion  of  the  brain  or  spinal  cord. ' ' 

The  principal  symptoms  have  already  been  mentioned,  and  taken 
as  a  whole,  make  a  fairly  characteristic  picture. 

Kernig's  Sign. — This  is  present  in  all  forms  of  meningitis.  If 
the  thigh  is  flexed  to  a  right  angle  on  the  body,  the  laiee  cannot  be 
straightened  if  there  be  meningitis. 

Lumbar  Puncture. — This  is  a  harmless  procedure,  which  is  made 
with  a  small  aspirator  or  antitoxin  needle  with  slightly  blunted 
point  and  edges.  A  spinal  anesthesia  needle  of  irido-platinum  is 
preferable.  It  can  be  done  without  geiieral  anesthesia  as  a  rule, 
by  the  use  of  the  ethyl  chloride  spray,  but  in  children  a  few  breaths 
of  chloroform  or  ethyl  chloride  make  it  entirely  painless.  The 
patient  is  turned  on  the  right  side,  with  the  knees  drawn  up,  the 
back  bowed,  and  the  left  shoulder  forward. 

The  spinous  processes  are  identified  by  touch,  and  the  needle 
entered  to  the  side  of  the  median  line,  thrusting  upward  and  in- 
ward into  the  third  lumbar  interspace  to  a  depth,  in  infants  of 
about  1  inch,  and  in  adults  nearly  2  inches.  It  is  needless  to  say 
that  this  must  be  done  under  the  strictest  aseptic  precautions. 
The  skin  is  most  easily  and  completely  sterilized  by  painting  with 
iodine,  without  previous  washing,  until  a  dark  brown  color  results. 
The  needle  should  be  carefully  boiled,  or  if  of  irido-platinum,  may 
be  heated  to  redness.  After  concluding  the  operation  the  punc- 
ture should  be  sealed  with  collodion. 

The  fluid  runs  usually  drop  by  drop,  and  is  generally  turbid, 
but  may  be  bloody  or  rarely  clear,  in  the  presence  of  meningitis. 
The  pressure  reaches  sometimes  as  high  as  250-300  millimeters  of 
mercury,  the  normal  being  about  120  mm. 

Cultures  should  be  prepared,  and  coverslip  preparations  made 
and  studied  at  once.  Centrifugalization  of  the  fluid  may  aid  in 
concentrating  the  cells  and  bacterial  flora  so  that  diagnosis  is  easier, 
but  it  can  frequently  be  made  from  the  unsedimented  fluid  by  the 
aid  of  the  stained  coverslip  preparations.  There  is  usually  no 
difficulty  in  distinguishing  between  the  pneumococcus  and  the 
intracellularis.  Should  no  organisms  be  found,  and  tuberculosis 
be  suspected,  a  guinea-pig  should  be  inoculated. 


THE   MENINGITIS   GROUP.  165 

Prognosis. — The  mortality  ranges  in  different  epidemics  from 
20  per  cent  to  75  per  cent,  unless  the  Flexner  serum  is  used,  when 
the  mortality  is  much  reduced.  This  serum  is  not  at  present  to 
be  had  commercially,  but  the  Rockefeller  Institute  has  arranged 
for  a  supply  to  be  kept  in  competent  hands  at  most  of  the  large 
cities.  The  health  officer  should  know  to  whom  to  apply  in  order 
to  secure  for  the  sick  the  benefits  of  this  treatment,  and  on  the  out- 
break of  an  epidemic  or  the  occurrence  of  a  sporadic  case,  should 
arrange  to  avail  himself  of  it.  It  is  used  by  withdrawing  an 
amount  of  the  cerebrospinal  fluid  (50  c.c.  for  an  adult),  and  inject- 
ing a  less  amount  of  the  serum  (30  c.c). 

Diphtheria  antitoxin  has  apparently  been  of  benefit  in  some 
epidemics. 

The  Flexner  serum  is  valuable  not  only  for  the  reduction  of  the 
death-rate,  but  prevents  in  many  instances  the  deplorable  sequelae 
which  are  really  worse  than  death. 

Prophylaxis. — No  certain  methods  are  yet  available.  All  bodily 
discharges  and  especially  those  from  the  nose  and  throat  should 
be  thoroughly  disinfected.  The  quarantine  should  last  at  least 
14  days  from  the  first  appearance  of  the  disease,  and  should  be 
continued  till  the  patient  has  recovered.  Disappearance  of  the 
diplococci  from  the  nasal  secretion  for  several  successive  days  might 
form  the  period  for  release  from  quarantine.  Carriers  should  be 
sought  for  as  in  diphtheria,  and  if  found,  isolated  until  the  disap- 
pearance of  the  germ. 

Disinfection. — Formaldehyd  fumigation  for  6  hours. 


CHAPTER  XV. 
THE  VENEREAL  GROUP. 

This  is  a  group  of  four  diseases,  of  which,  but  two  will  be  con- 
sidered. The  third  member  of  the  group,  chancroid,  is  omitted 
because  it  is  not  a  constitutional  disease  nor  one  of  sociological 
importance,  and  because  the  same  measures  which  avail  to  prevent 
the  two  which  are  here  considered  will  also  prevent  chancroid. 
The  fourth  disease  is  Frambesia  or  Yaws,  a  spirillar  disease  due 
to  the  Spirocliceta  {Treponema)  pertenuis  and  is  somewhat  similar 
to  syphilis,  being  sometimes  propagated  through  sexual  inter- 
course and  sometimes  through  innocent  inoculation.  It  is  exclu- 
sively a  disease  of  the  tropics,  and  there  seems  to  be  but  little 
chance  of  its  establishment  in  this  country.  Should  it  ever  be 
introduced,  the  same  means  employed  to  limit  or  prevent  syphilis 
will  be  found  efficacious. 

The  two  diseases  considered  in  this  chapter  are  of  very  great 
sociological  importance,  since  both  in  different  ways  tend  to  crowd 
the  charitable  institutions  with  invalids  and  blind,  and  both  in- 
crease the  number  of  sterile  women  and  sterile  men.  For  this 
reason,  the  venereal  diseases  are  worthy  of  our  most  earnest  study 
as  sanitarians  and  our  best  efforts  to  limit  or  end  their  ravages. 
Unfortunately  a  foolish  prudery,  which  now  bids  fair  to  be  in 
some  degree  dissipated,  has  prevailed  in  regard  to  them.  The 
campaign  against  venereal  disease  has  been  left  too  largely  to  well- 
meaning  but  poorly  informed  lay  fanatics,  while  the  sanitarians 
and  medical  and  lay  sociologists  have  avoided  the  subject. 

These  two  diseases  are  to  be  fought  by  stirring  up  moral  senti- 
ment against  them,  but  it  must  not  for  a  moment  be  forgotten 
that  the  sexual  appetite  is  the  most  dominant  of  all  the  calls  of 
instinct  except  hunger,  and  that  when  all  that  can  be  done  in  the 
way  of  education  has  been  accomplished,  there  remains  a  residue 
that  in  our  present  state  of  society  must  be  protected  against,  in 
order  that  the  innocent  may  be  defended.  Therefore  as  sanita- 
rians, having  done  all  we  can  on  moral  grounds,  we  must  endeavor 

166 


THE   VENEREAL   GROUP.  167 

to  afford  physical  protection,  in  order  that  the  weak  and  erring 
may  be  protected  against  themselves,  and  not  make  themselves  or 
their  children  burdens  on  society. 

SYPHILIS. 

Definition. — A  specific  disease  of  slow  evolution,  caused  by  the 
Spirochata  (Treponema)  pallida,  propagated  by  inoculation  (ac- 
quired syphilis)  or  by  hereditary  transmission  (congenital  syphi- 
lis). (Osier.)  The  morphological  status  of  the  pale  spirochete 
is  not  definitely  established,  different  authors  classifying  it  as  a 
bacterium  and  as  a  protozoon.  On  chemical  grounds  the  latter 
seem  to  have  the  best  of  the  argument,  however,  since  the  organic 
arsenic  compounds  are  highly  effective  against  the  spirochtete  and 
many  parasitic  protozoa,  but  are  ineffective  against  all  known 
bacteria. 

Etiology. — The  disease  is  normally  propagated  by  sexual  contact, 
but  may  be  acquired  by  kissing,  by  unclean  instruments  of  dentist 
or  surgeon,  by  surgeons  and  nurses  in  the  discharge  of  their  pro- 
fessional duties  and  by  intrauterine  infection,  as  well  as  in  less 
common  ways. 

Incubation. — The  primary  sore  usually  appears  after  a  period 
of  3  to  4  weeks  has  elapsed  after  the  infection. 

Symptoms. — Syphilis  is  so  varied  in  its  symptomatology  that  for 
a  proper  description  the  reader  is  referred  to  any  of  the  standard 
works  on  the  subject,  space  forbidding  its  proper  consideration 
here.  Only  those  symptoms,  accompaniments  and  sequelae  will  be 
noted  which  possess  sociological  or  sanitary  importance: 

(a)  The  primary  sore  and  mucous  lesions  are  important  as 
being  the  ordinary  lesions  which  propagate  the  disease. 

(b)  The  eye  is  affected  with  iritis,  irido-cyclitis  and-  retinitis, 
causing  blindness  or  impairment  of  vision,  and  the  punctate  kera- 
titis of  hereditary  syphilis  is  equally  effectual  in  the  same  direction 
by  rendering  the  cornea  hazy  or  opaque. 

(c)  Sclerotic  changes  take  place  in  the  ear,  notably  in  the  laby- 
rinth, which  cause  hopeless  deafness. 

(d)  Endoarteritis  causes  the  arteries  to  lose  their  vitality  and 
elasticity  and  by  yielding  to  the  blood-pressure  aneurisms  are 
formed  and  cerebral  and  spinal  hemorrhages  result. 

(e)  The  central  nervous  system  is  affected  by  sclerotic  changes 
which  result  in  the  various  progressive  paralyses  and  locomotor 


168  PRACTICAL   SANITATION. 

ataxia.     Gummatous  tumors  may  cause  death  or  prolonged  and 
disqualifying  paralyses. 

(f)  The  peripheral  nerves  may  become  the  seat  of  chronic  in- 
flammation resulting  in  long  invalidism. 

(g)  Most  important  to  the  sociologist  is  the  great  tendency  of 
pregnant  syphilitic  women  to  abort,  and  if  the  offspring  should  be 
carried  to  term,  to  have  it  still-born  or  perish  in  infancy,  or  if  it 
should  live,  to  have  it  attacked  by  some  of  the  concomitants  noted 
above. 

Diagnosis. — AVhere  this  cannot  be  made  by  the  history  or  symp- 
toms, it  is  sometimes  possible  by  the  serum  reactions  of  Wassermann 
and  Noguchi,  described  in  Part  III,  page  385. 

Prognosis. — The  sanitarian  should  never  forget  that  with  a 
chronic  disease  such  as  syphilis,  intelligent  treatment  is  a  public 
as  well  as  a  private  duty,  and  should  urge  all  syphilitics  to  avail 
themselves  of  the  best  treatment  available.  Modern  therapeutics 
have  largely  divested  syphilis  of  its  danger  to  life,  and  the  prog- 
nosis should  therefore  be  always  as  favorable  as  possible  as  to 
ultimate  recovery,  provided  the  patient  submits  to  proper  treat- 
ment. The  employment  of  hypodermic  medication  by  arsenical 
and  mercurial  compounds,  by  shortening  the  time  required  for 
treatment  and  increasing  its  efficiency  is  not  only  a  private  but  a 
public  service,  as  shortening  the  infective  period. 

Prophylaxis. — The  prophylaxis  of  syphilis  will  be  considered 
with  that  of  gonorrhea. 

GONORRHEA. 

Definition.— An  acute  contagious  disease  of  mucous  and  serous 
membranes  due  to  infection  with  the  gonococcus,  and  usually  propa- 
gated by  sexual  contact. 

Symptoms. — From  3  to  10  days,  occasionally  longer,  after  an 
impure  intercourse,  the  meatus  urinarius  in  either  sex  is  attacked 
by  a  burning  itching  sensation,  worse  on  urinating,  and  on  exami- 
nation the  lips  are  found  to  be  stuck  together.  The  discomfort 
increases,  the  discharge  becomes  more  profuse  and  after  2  or  3 
days  is  thick  and  creamy  from  the  male  urethra  and  the  female 
vagina.  After  10  days  or  2  weeks,  the  discharge  usually  becomes 
more  watery  and  the  acuter  symptoms  are  somewhat  relieved. 
There  is  always  a  tendency  for  the  invasion  of  the  deeper  structures, 
causing  a  part  of  the  complications  hereafter  to  be  mentioned: 


THE   VENEREAL   GROUP.  169 

A.     In  the  Male. 

(a)  Stricture    of    Die    iirpthra,    which    freqxicntlj'    results    in    chronic    in- 

validism. 

(b)  Prostatitis,  with  like  sequelae. 

(c)  Epididymitis,  with  sterility. 

B.  In  the  Female. 

(a)      Endometritis  and  salpingitis,  with  attendant  invalidism  and  sterility. 
(h)      Oplithalmia  neonatorum  in  the  oflfspring. 

C.  In  Both  Sexes. 

(a)  Conorrlieal  rheumatism    (arthritis)    a  very  disabling  complication. 

(b)  Gonorrheal  endocarditis,  a  very  serious  and  often  fatal  complication. 

(c)  Gonorrheal   conjunctivitis    (see   Chapter  XVIII),   a   lesion   frequently 

resulting  in  partial  or  total  blindness. 

Unclean  hands  or  towels  may  convey  the  virus  to  the  eyes  of  the 
patient  or  others,  and  in  institutions  may  cause  almost  every  child 
to  be  attacked  by  conjunctivitis  or  gonorrhea  of  the  genitalia. 
Those  having  the  disease  or  caring  for  it  in  others  must  invariably 
disinfect  the  hands  at  once. 

THE  GENERAL  PROPHYLAXIS  OF  VENEREAL  DISEASE. 

The  sociological  importance  of  venereal  disease  has  already  been 
dwelt  upon  at  some  length.  It  goes  far  to  justify  strenuous  meas- 
ures to  abate  these  "Black  Plagues."  Certain  measures  have  been 
tried  and  found  wanting.  Among  others,  the  inspection  of  prosti- 
tutes and  their  segregation  into  districts  under  police  supervision 
have  been  tried  in  many  places,  and  after  trial  abandoned.  The 
reason  for  this  is  the  fact  that  the  publicly  known  prostitute  is  not 
the  greatest  danger,  but  the  clandestine  prostitute  who  plies  her 
trade  in  dark  corners,  under  constant  fear  of  detection.  The  public 
prostitute,  who  has  been  instructed  in  her  business,  values  her 
clientele,  and  insists  on  a  rough  and  ready  examination  of  her 
prospective  customer  which  will  reveal  at  least  the  grosser  lesions 
of  venereal  disease,  and  after  intercourse  provides  him  with  toilet 
requisites  including  antiseptics  and  insists  on  their  use,  sometimes 
applying  them  herself.  The  clandestine  prostitute  has  not  usually 
the  facilities  for  her  own  protection  nor  that  of  her  client. 

The  first  step  which  should  be  insisted  on  is  to  make  these  diseases 
reportable,  the  records  being  kept  wholly  confidential.  It  is  just 
as  important  that  syphilis  and  gonorrhea  be  reported  as  that  small- 
pox should  be — indeed  more  so,  for  they  are  more  widespread  and 


170  PRACTICAL  SAiSriTATiON. 

in  the  aggregate  vastly  more  fatal.  Genitourinary  hospitals  and 
wards  should  be  enlarged,  and  those  affected  urged  or  forced  to 
enter  them  if  they  cannot  be  properly  cared  for  in  their  homes. 
The  stigma  of  venereal  disease  should  be  removed  from  syphilis 
especially,  and  the  fact  made  widely  known  that  it  is  very  fre- 
quently indeed  innocently  contracted.  Disorderly  houses  known 
to  harbor  infected  women  should  be  placarded  with  the  words  ' '  Con- 
tagious Disease, ' '  a  method  which  is  very  effective  in  inducing  these 
women  to  enter  hospitals  which  afford  them  not  only  physical  cure 
but  a  chance  for  moral  rehabilitation.  Physical  examinations 
should  be  made  at  frequent  but  irregular  intervals,  swabs  being 
made  from  the  cervix  uteri  and  urethra  and  planted  on  appropriate 
culture  media.  In  the  event  of  a  positive  result  being  found,  the  in- 
mate is  given  the  choice  of  entering  the  hospital  or  causing  the 
house  to  be  placarded,  which  invariably  causes  her  to  select  the 
former  alternative.  These  means  are  effective  against  only  a  part 
of  the  infected  population,  but  reduce  the  number  by  that  much. 
Certificates  of  non-infection  should  never  be  given,  either  to  those 
who  are  discharged  from  the  hospitals  or  inmates  of  houses,  but 
infected  women  should  never  be  discharged  from  treatment  with 
active  disease,  being  held  under  threat  of  police  court  action,  if 
necessary. 

No  opportunity  should  ever  be  let  pass  to  point  out  the  multiform 
dangers  of  impure  sexual  intercourse.  The  greater  the  public 
knowledge  on  the  subject,  the  less  likely  the  danger  of  contracting 
these  dangerous  diseases.  It  should  always  be  insisted  on  that  they 
are  never  trifling  matters,  and  that  of  the  two,  syphilis  is  less  dan- 
gerous to  life.  But  if  the  man  is  obdurate,  he  should  be  instructed 
to  use  the  methods  now  in  use  in  the  military  services  which  have 
greatly  reduced  the  amount  of  venereal  infection : 

1.  A  1 :1000  bichloride  solution  or  a  1 :500  permanganate  solu- 
tion is  used  to  cleanse  the  parts. 

2.  An  ointment  of  10  per  cent  argyrol  in  lanolin  is  injected  into 
the  urethra. 

3.  20  grains  of  a  33  per  cent  calomel  ointment  made  with  a 
lanolin  base  is  rubbed  over  the  parts. 

If  this  prophylactic  treatment  is  well  applied,  the  danger  of 
venereal  infection  is  minimized.  Packets  containing  these  anti- 
septics in  convenient  form  are  now  put  up  by  several  houses. 

With  the  woman,  the  above  treatment  cannot  be  used.     She  is 


THE  VENEREAL  GROUP.  171 

therefore  forced  to  depend  on  the  bichloride  or  permanganate  ap- 
plied by  douche,  or  better,  by  a  pledget  of  absorbent  cotton. 

The  advocacy  of  such  measures  as  the  above-mentioned  prophy- 
lactics does  not  lose  sight  of  the  moral  aspects  of  the  case,  nor 
condone  the  immorality.  For  the  public  good  it  endeavors  to  pre- 
vent or  minimize  the  ill  effects  of  the  sins  it  cannot  abolish.  In 
the  end  public  opinion  v^^ill  be  led  to  support  all  measures  for  the 
suppression  of  venereal  disease  as  it  now  does  in  large  measure 
those  for  the  prevention  of  tuberculosis,  yet  only  tvi^enty  years  ago 
the  present  status  of  antituberculosis  work  seemed  as  remote  and 
Utopian  as  at  present  seem  efforts  for  preventing  venereal  disease. 
The  sanitarian  must  lead  in  the  work,  as  his  training  and  bent  of 
mind  naturally  fit  him  to  do. 


CHAPTER  XVI. 

NUTRITIONAL  DISEASES. 

There  are  three  diseases  of  importance  to  the  health  officer  be- 
cause they  involve  considerable  numbers  of  people,  becoming'  almost 
epidemic  at  times  and  bearing  an  appearance  of  infectivity,  which 
are  really  diseases  of  nutrition.  Careful  experimentation  and 
analysis  covering  large  numbers  of  cases  has  pretty  definitely  ex- 
cluded all  causes  except  a  dietary  deficient  in  some  important  par- 
ticular, although  doubtless  general  unhygienic  surroundings  which 
tend  to  depress  the  vitality  may  contribute  somewhat.  These  dis- 
eases are  pellagra,  beriberi  and  scurvy.  The  latter  two  have  been 
abolished  wherever  it  has  been  possible  to  provide  a  proper  diet, 
and  there  is  strong  reason  to  believe  that  the  first  may  be  vanquished 
in  the  same  way. 

PELLAGRA. 

Definition. — Pellagra  is  a  chronic  disease,  showing  periodical 
acute  exacerbations,  according  to  one  view,  or  subject  to  reinfec- 
tion according  to  the  other  view,  which  is  characterized  by  debility, 
erythema  passing  over  into  dryness  and  scaliness  of  the  skin,  diges- 
tive and  nervous  disturbances. 

Etiology. — There  have  been  four  schools  of  opinion  relative  to 

pellagra,  the  oldest  of  which  (the  Ital- 
ian) believes  that  pellagra  .is  due  to 
chronic  poisoning  from  eating  spoiled 
maize ;  the  second,  that  of  Sambon,  attri- 
butes to  it  infectiousness  and  a  trans- 
mission by  the  SimuUum  fly;  the  third 
sees  in  it  a  chronic  poisoning  by  colloidal 
silicic  acid  from  soil-waters  drunk ;  the 
Fig.  2.— The  simuiium  fly  and  fourth,  that  of  Goldberger,  that  it  is  a 
larva.    (After  Comstock.)         ^^j^^^^^  ^^j  .  <  under-uourishment "  due  to  a 

bad]y-balan(!e(l  ration.     This  is  borne  out  by  the  fact  that  it  is  en- 
tirely a  disease  of  poverty,  except  when  it  occurs  among  the  insane. 

172 


NUTRITIONAL   DISEASES.  173 

Neither  in  our  own  or  the  Italian  services  has  it  been  known  to  de- ' 
velop  in  the  Army  or  Navy,  in  any  man  who  did  not  have  it  before 
or  at  the  time  of  enlistment.  Attendants  and  officials  in  asylums 
where  there  are  many  pellagrins  do  not  develop  the  disease,  and 
on  the  other  hand  patients  many  years  in  these  places  do,  which  is 
a  fact  hard  to  harmonize  with  any  theory  of  winged-insect  trans- 
mission. 

The  opponents  of  this  theory  point  out  that  proper  rations  are 
alloivcd  to  patients  in  asylums,  which  is  perfectly  true,  but  they 
miss  the  essential  point,  which  is  that  the  cation  must  be  con- 
sumed. In  orphanages  and  similar  institutions  dealing  with  the 
mentally  normal,  where  pellagra  had  formerly  been  rife,  the  change 
to  a  properly  balanced  ration  has  resulted  in  a  disappearance  of 
the  disease.  Investigation  of  the  diet  of  pellagrins  has  uniformly 
shown  it  to  be  far  too  high  in  carbohydrates  and  deficient  in  nitro- 
gen content.  With  the  limitation  of  this  portion  of  the  ration  and 
a  substitution  of  fresh  meats,  milk,  eggs  and  legumes  (either  fresh  or 
dried),  a  prompt  improvement  has  taken  place,  even  without  medi- 
cation. With  insane  pellagrins  forced  or  tube  feeding  is  necessary 
in  some  cases,  but  if  the  food  is  actually  taken,  a  betterment  oc- 
curs. 

Symptoms. — Prodromes. — Lassitude,  vertigo,  headache,  general 
malaise,  and  sometimes  mild  digestive  disturbances ;  all  these  symp- 
toms are  absent  in  some  cases. 

First  Stage. — Burning  sensations  in  mouth  or  stomach,  altered 
sense  of  taste,  loss  of  appetite  and  frequently  salivation.  Dys- 
peptic symptoms,  with  flatulence,  vomiting  and  abdominal  pain, 
diarrhea  (occasionally  constipation)  ;  bowel  passages  sometimes 
containing  mucus  and  blood  and  being  voided  with  pain  and  tenes- 
mus. Tongue  coated,  and  buccal  mucous  membrane  reddened,  with 
small  blisters  or  even  superficial  ulceration. 

In  a  short  time  the  characteristic  redness  of  the  skin  appears, 
coming  out  symmetrically  and  nearly  always  on  uncovered  parts 
of  the  body.  It  is  accompanied  by  itching  and  burning  of  the  skin, 
and  swelling. 

There  is  muscular  weakness  especially  of  the  lower  limbs,  and 
the  patients  tire  easily. 

The  temperature  is  usually  normal,  but  may  be  slightly  elevated 
at  times,  but  the  presence  of  much  fever  denotes  complications  of 
some  kind. 


174  PRACTICAL   SANITATION. 

Vertigo  is  often  an  annoying  symptom,  as  are  headache  and  in- 
somnia; neuralgias  may  be  severe,  especially  in  the  back,  with 
cramps  in  the  extremities.  The  knee-jerks  are  apt  to  be  exagger- 
ated. 

Eye  sjanptoms  are  frequent,  ranging  from  diplopia  and  ambly- 
opia to  cataract. 

Blood  changes  are  unimportant,  and  urinary  changes  except  al- 
buminuria and  the  presence  of  the  diazo  reaction  are  not  frequent 
or  characteristic. 

Second  Stage. — ^This  is  marked  by  an  increase  in  the  severity  of 
all  the  above  noted  symptoms.  A  marked  anemia  supervenes;  the 
skin  becomes  hard,  dry,  cracked  and  pigmented;  the  tongue  is 
smooth  and  bare  of  epithelium  (bald  tongue).  The  diarrhea  be- 
comes more  annoying  and  persistent,  and  is  either  serous  or  bloody ; 
it  may  be  painless  and  if  continued  brings  on  the  third  or  cachectic 
stage. 

The  nervous  symptoms  become  more  prominent,  and  to  the  in- 
crease of  these  noted  under  the  first  stage  are  added  the  psychic 
symptoms,  which  usually  take  the  form  of  melancholia.  In  the 
milder  cases  there  may  only  be  a  slowness  of  thought,  mental  feeble- 
ness and  aversion  to  any  kind  of  activity.  The  severer  cases  pre- 
sent delusions  of  persecution,  anxiety  and  frequently  religious 
ideas  predominate.  Suicidal  tendencies  are  common  while  homi- 
cidal ideas  are  rare.  Food  may  be  refused.  Delirium  of  a  melan- 
cholic character  may  occur,  as  may  circular  insanity  and  paranoia, 
while  the  end  picture  is  apt  to  be  dementia. 

The  muscular  system  suffers  progressive  enfeeblement,  and  par- 
tial paralysis,  hemiplegia  and  paraplegia  may  occur.   . 

A  state  like  tetany,  with  paroxysmal,  painful  tonic  contractions 
of  the  muscles  are  observed. 

The  gait  is  usually  paralytic  or  paralytic-spastic,  never  ataxic. 
There  are  tremors  of  the  upper  extremities,  head  and  tongue  in 
many  cases. 

Various  minor  symptoms  also  occur. 

Third  Stage.  The  Terminal  or  Cachectic  Stage. — The  symptoms 
of  the  second  stage  are  aggravated  and  emphasized,  but  new  ones 
do  not  supervene.  The  cachexia  is  the  most  prominent  symptom, 
with  the  mental  symptoms  a  close  second.  The  diarrhea  often 
becomes  uncontrollable  and  is  the  immediate  cause  of  death. 
The  paralyses  and  anemia  also  may  terminate  the  case,  or  some 


NUTRITIONAL    DISEASES.  175 

intercurrent    disease    as    jDulmonary    tuberculosis    may    intervene. 

Typhoid  Pellagra. — In  this  form  the  symptoms  of  the  pellagra 
become  hyperacute  and  there  are  present  all  the  symptoms  of  the 
profound  prostration  known  as  the  typhoid  state.  It  must  not  be 
confounded  with  true  typhoid.  Death  usually  occurs  in  this  form 
within  1  or  2  weeks. 

Pellagrous  Erythema. — This  is  probably  due  to  the  chemical 
action  of  the  sun's  rays  on  a  deficiently  resistant  skin,  and  appears 
first  on  the  face  and  extensor  surfaces  of  the  extremities  if  they  are 
exposed  to  sunlight,  and  afterwards  on  the  flexor  surfaces,  but  the 
palms  and  soles  escape.  Earely,  covered  parts  of  the  body  are 
affected  or  the  eruption  is  general.  It  usually  develops  first  on  the 
backs  of  the  hands  with  itching  and  burning,  almost  precisely 
similar  to  sunburn.  The  red  disappears  on  pressure  but  returns 
as  soon  as  the  pressure  is  removed.  There  may  be  large  blisters 
with  serum,  which  may  become  bloody  or  purulent.  There  may 
also  be  a  thickening  and  drying  of  the  skin,  with  subsequent  peeling, 
without  the  formation  of  blisters.  The  scaling  may  occur  in  large 
flakes.  The  skin  is  pigmented  for  some  time  after  the  completion 
of  the  drying  and  desquamation.  After  repeated  attacks  it  be- 
comes thickened,  hard  and  dry,  its  elasticity  is  partly  lost,  and 
fissures  or  thick  crusts  form,  or  there  may  be  small  ulcers  left  after 
the  peeling  takes  place.  Atrophic  lines  like  those  on  the  abdomen 
of  a  woman  who  has  borne  children  are  seen  in  old  cases.  In  a 
few  cases  the  rough  skin  is  lacking — pellagra  sine  pellagra.  This 
is  believed  to  represent  only  a  temporary  condition. 

Duration. — ^Pellagra  is  an  exceedingly  chronic  disease  ordinarily, 
and  is  very  irregular  in  its  development.  A  severe  attack  one  year 
may  be  followed  by  a  light  one  the  next.  An  early  spring  favors 
the  early  recurrence  of  the  attack.  The  disease  is  always  more 
rapid  and  grave  in  children.  The  stages  as  here  outlined  have 
nothing  to  do  with  time,  since  some  cases  progress  more  in  one  year 
than  others  in  twenty,  and  indeed  some  cases  remain  in  the  first 
stage  for  twenty  years. 

Diagnosis. — The  diagnosis  is  based  on  the  symptoms  as  here 
outlined,  and  particularly  on  the  skin  symptoms. 

Prognosis. — Always  serious,  but  dependent  on  the  possibility  of 
removing  the  patient  to  proper  surroundings  and  a  good  food  sup- 
ply. In  the  first  stage,  recovery  is  the  rule,  in  the  second  it  may 
occur,  but  the  intelligence  is  apt  to  be  permanently  enfeebled;  in 


176  PRACTICAL   SANITATION. 

the  third,  death  is  the  rule.  Recovery  may  occur  from  typhoid 
pellagTa,  but  is  very  rare. 

It  is  an  important  disease  on  account  of  the  large  number  of 
people  involved  and  the  destructive  effects  on  society  as  well  as  the 
individual. 

Prophylaxis. — The  prevention  of  this  disease  lies  mostly  in  the 
education  of  the  people  to  choose  and  prepare  rightly  a  properly 
balanced  ration,  in  which  fresh  meats,  milk  and  eggs  where  the 
cost  is  not  prohibitive,  and  fresh  or  dried  (not  canned)  beans, 
peas  and  other  legumes  for  the  very  poor,  take  the  place  of  a  large 
portion  of  the  grits,  molasses,  corn  meal  mush  and  fat  salt  pork 
which  they  now  eat.  Schools  of  domestic  science  can. do  more  than 
drug  stores  in  this  direction. 

The  disease  is  widespread  in  the  Southern  States,  and  extends  at 
least  as  far  north  as  Illinois,  Kansas  and  Indiana.  Reliable  sta- 
tistics of  morbidity  and  mortality  for  the  United  States  are  not 
available,  since  the  collection  of  vital  statistics  is  very  faulty  over 
most  of  the  affected  area. 

BERIBERI. 

Synonym. — Kakke  (Japanese). 

Definition. — A  multiple  neuritis  involving  any  or  all  of  the  peri- 
pheral nerves,  due  to  an  improper  dietary. 

Distribution. — Beriberi  is  exceedingly  prevalent  in  the  Orient, 
particidarly  in  those  parts  where  rice  is  the  staple  article  of  diet. 
In  1910  there  were  3,334  deaths  in  the  Philippine  Islands  alone  and 
in  the  Malay  States  during  the  last  20  years  there  have  been  150,- 
000  cases  with  30,000  deaths  in  the  government  institutions  (Brad- 
don).  Vedder  estimates  a  mortality  of  200,000  yearly  in  China 
from  this  cause.  It  has  also  been  reported  from  Louisiana,  New 
Jersey  and  New  England. 

Etiology. — In  the  Orient  beriberi  is  invariably  associated  with 
the  use  of  highly  milled  rice.  Rice  is  a  food  naturally  deficient  in 
proteid  and  the  polishing  process  reduces  the  proteid  still  farther 
and  also  takes  out  certain  amines  soluble  in  water  and  alcohol  which 
seem  to  be  essential  for  the  ])roper  assimilation  of  the  food.  Numer- 
ous most  exacting  and  conclusive  experiments  on  fowls  and  also  on 
bodies  of  men  under  discipline  and  close  control  have  proved  that 
beriberi  is  a  nutritional  disease.  The  change  to  a  proper  dietary 
has  driven  the  disease  out  of  the  Japanese  navy  where  it  was  for- 


NUTRITIONAL    DISEASES.  177 

merly  excessively  prevalent.  The  Philippine  Scouts,  a  picked  body 
of  men,  5,000  in  number,  on  a  ration  consisting  principally  of  24 
ounces  of  rice  per  man,  had  an  incidence  of  about  600  cases  per  year. 
With  a  well-balanced  ration  adapted  to  their  taste,  it  has  entirely 
disappeared.  This  disappearance  was  not  gradual,  but  almost  in- 
stantaneous. 

The  voyage  of  the  German  commerce-destroyer  Kronprinz  Wil- 
hclm  which  put  into  Newport  News,  April  13,  1915,  after  a  voyage 
cf  210  days  out  of  New  York  during  which  she  touched  nowhere, 
affords  most  striking  proof  of  this  theory.  Owing  to  inability  to 
obtain  fresh  supplies  during  the  latter  part  of  the  voj^age,  all 
aboard  were  compelled  to  subsist  on  rice.  Out  of  a  total  of  565 
crew  and  prisoners  aboard,  110  came  down  with  beriberi. 

]\Ianson  and  others  have  sought  to  find  evidence  of  infection  in 
this  disease,  but  in  the  face  of  accumulated  facts  like  the  above, 
they  are  hardly  to  be  maintained,  and  in  fact  ai'e  practically  aban- 
doned. 

Symptoms. — The  earliest  symptoms  noted  in  the  author's  expe- 
rience are  pain  and  tenderness  in  the  calf  and  over  the  peroneal  and 
anterior  tibial  nerves.  Anesthesia  of  the  affected  areas  follows 
later,  but  may  be  only  partial.  From  this  point  the  disease  takes 
on  three  types  which  may  change  one  to  the  other  with  great 
rapidity.  In  the  first  or  wet  form  there  is  a  local  or  general 
anasarca  which  may  extend  even  to  the  face.  In  the  second  or  dry 
form  the  muscles  are  flabby  and  atrophied.  The  amount  of  urine 
passed  determines  the  type  between  the  two.  In  the  third  or  car- 
diac form  the  vagi  are  involved  and  the  heart  becomes  exceedingly 
irritable.  In  all  three  forms  there  are  fever,  muscular  wealmess  or 
actual  paralysis,  anesthesia,  loss  of  reflexes  and  atrophy  of  the 
muscles.  In  chronic  beriberi  the  same  symptoms  are  observed 
minus  the  fever.  Acute  cardiac  beriberi  may  kill  in  24  hours  as 
the  writer  has  seen,  without  the  development  of  any  symptoms  ex- 
cept the  earliest. 

Prognosis. — The  mortality  A^aries  from  3  to  70  per  cent,  accord- 
ing to  the  proportion  of  cardiac  cases.  In  the  Philippine  Scouts 
and  also  in  the  later  Japanese  experience,  the  mortality  has  been 
about  10  per  cent. 

Prophylaxis. — The  prevention  of  beriberi  lies  solely  in  the  use  of 
undermined  rice  or  if  highly-milled  rice  is  used,  the  addition  of 
some  legume  to  the  ration.     Simple  as  this  is,  it  is  sometimes  a 


178  PRACTICAL.   SANITATION. 

matter  of  considerable  economic  difficulty,  since  modern  mills  are  al- 
most all  so  made  as  to  furnish  the  latter  grade.  On  public  works 
of  any  description  where  rice  forms  a  large  part  of  the  ration,  as 
when  Orientals  are  employed,  the  addition  of  beans,  peas  or  lentils 
and  their  consumption,  is  a  matter  of  necessity.  If  fresh  meat  can 
be  issued  in  sufficient  quantity,  or  if  wheat  or  barley  can  be  used, 
as  in  the  case  of  the  northern  Chinese,  this  is  not  necessary,  but 
should  be  done  as  a  matter  of  precaution. 

SCURVY. 

Synonyms. — Scorbutus;  Scorbutic  Purpura. 

Definition. — A  disease  characterized  by  a  dyscrasic  state  of  the 
blood,  associated  with  subcutaneous  or  submucous  hemorrhages,  by 
a  peculiar  spongy  state  of  the  gums,  and  extreme  general  weakness 
(Tyson). 

Etiology. — Scurvy  is  a  nutritional  disease  due  apparently  to  a 
diet  from  which  the  salts  of  the  vegetable  acids  are  M^anting.  It 
has  been  experimentally  produced  in  animals  by  such  a  diet. 

Distribution. — Scurvy  is  found  wherever  people  are  compelled  to 
subsist  on  a  ration  from  which  fruits  and  fresh  vegetables  are  lack- 
ing. This  applies  to  sailing  vessels,  prisons  and  almshouses,  and  in 
the  winter  of  the  Frigid  Zones.  It  is  also  often  seen  during 
famines  such  as  those  of  recent  years  in  the  Orient.  During  the 
^Middle  Ages  it  was  exceedingly  common  and  armies  and  civil  popu- 
lations were  decimated  or  destroyed  by  it. 

Symptoms. — The  symptoms  are :  weakness  of  the  muscles ;  feeble 
heart  action ;  temperature  usually  normal ;  soft,  spongy  gums  and 
loosened  teeth ;  petechial  hemorrhages  under  the  skin  and  mucous 
membranes,  occurring  first  on  the  lower  extremities ;  and  sometimes 
necrosis  of  the  jaw. 

Prophylaxis. — The  use  of  fruit-juices  such  as  the  classical  lime- 
juice,  and  fresh  vegetables  of  which  onions,  potatoes  and  carrots  are 
best.  All  these  vegetables  are  now  furnished  desiccated  in  such  a 
way  as  to  leave  their  anti-scorbutic  properties  unimpaired  for  trans- 
portation to  places  where  the  use  of  the  fresh  article  is  not  prac- 
ticable. The  need  and  value  of  such  a  diet  is  shown  by  the  fact 
that  trappers,  prospectors  and  others  who  have  been  long  deprived 
of  them  will  eat  a  raw  potato  or  onion  like  an  apple,  and  with  even 
greater  enjoyment.  Such  dried  fruits  as  apples,  raisins,  and 
peaches  are  also  valuable  anti-scorbutics. 


CHAPTER  XVII. 
THE  RINGWORM  GROUP. 

The  infectious  diseases  of  the  skin  do  not  form  a  very  large  or 
important  part  of  the  health  officer's  work,  but  to  the  institutional 
physician  and  the  school  inspector  they  are  sometimes  sources  of 
much  worry. 

Of  the  diseases  here  considered,  one  is  of  unknown  etiology  and 
four  are  diseases  caused  by  fungi  somewhat  allied  to  the  moulds. 
Common  itch  (scabies)  and  the  skin  irritations  caused  by  lice  are 
discussed  in  Chapter  XIX,  as  is  the  "ground  itch"  by  which  the 
hookworm  gains  entrance  to  the  body. 

IMPETIGO  CONTAGIOSA. 

This  is  a  disease  most  frequently  found  in  children  but  some- 
times seen  in  adults.  It  may  appear  in  epidemic  form  or  sporadic- 
ally. It  affects  the  poorly  nourished  and  badly  fed  rather  oftener 
than  the  strong  and  well,  but  no  class  is  entirely  exempt.  The 
etiology  is  unknown. 

Symptoms. — The  eruption  begins  as  small  vesicles,  which  spread, 
form  pustules,  and  later  dry  and  form  crusts.  It  may  occur  on 
any  part  of  the  body,  but  is  more  common  on  the  face  and  hands. 
There  is  not  much  itching,  and  but  slight  constitutional  disturbance 
or  none.     If  properly  treated,  it  should  be  well  in  ten  days. 

There  should  be  no  difficulty  in  differentiating  this  disease  from 
smallpox,  but  the  differential  diagnosis  from  all  the  exanthemata 
will  be  found  on  page  81. 

Isolation. — The  subjects  of  impetigo  contagiosa  should  be  ex- 
cluded from  school,  and  if  inmates  of  institutions  should  be  isolated 
till  the  skin  has  been  entirely  clear  for  several  days. 

TINEA. 

There  are  three  forms  of  fungi  which  cause  the  diseases  known 
as  tinea :  tinea  trichophytina,  which  is  subdivided  into  tinea  tonsu- 
rans, ringworm  of  the  scalp  or  "scaldhead"  and  tiiiea  drcinata, 

179 


180  PRACTICAL   SANITATION. 

which  is  more  usually  called  ringworm  by  the  laity;  tinea  favosa, 
f aviis ;  tinea  versicolor. 

RINGWORM  OR  BARBER'S  ITCH. 

Ringworm  or  barber's  itch,  as  it  is  called  when  it  affects  the 
bearded  part  of  the  face,  is  due  to  a  microscopic  fungus  known  as 
Trichophyton  tonsurans.  The  specific  name  is  derived  from  the 
fact  that  the  growth  of  the  fungus  in  and  around  the  hair  follicles 
causes  the  hair  to  fall  out  permanently.  It  affects  the  hairy  scalp 
only  in  children,  but  in  men  the  bearded  portion  of  the  face  is  often 
attacked.  In  the  circinate  form  it  may  appear  on  any  part  of  the 
body  and  the  lesions  may  be  multiple. 

]\IODE  OF  Infection. — This  fungus  is  carried  on  unclean  hands, 
towels,  razors  or  toilet  articles.  For  this  reason  the  sanitation  of 
barber-shops  is  a  matter  for  some  concern.  AVhile  the  disease  is 
not  a  serious  one  so  far  as  danger  to  life  is  concerned,  it  may  very 
considerably  disfigure. 

Isolation. — Children  in  school  should  be  excluded  until  the 
lesions  are  entirely  well ;  in  institutions  they  should  be  isolated. 

FAVUS. 

This  disease  is  caused  by  the  growth  of  the  Achorion  schoenleinii. 
It  appears  in  the  form  of  small  yellow  cup-shaped  crusts,  which 
have  a /'mousey"  odor.  It  appears  on  almost  any  part  of  the 
body,  but  affects  the  scalp  by  preference.  These  crusts  may  be- 
come confluent,  covering  large  areas  Avith  a  thick  scab.  The  disease 
is  much  more  difficult  to  handle  than  ringworm.  Isolation  is  the 
same  as  for  that  disease. 

TINEA  VERSICOLOR. 

This  is  caused  by  the  Microsporon  furfur  and  manifests  itself  by 
fine  yellowish  scales,  usually  situated  on  the  trunk.  The  isolation 
is  as  for  the  two  preceding. 

DHOBIE  ITCH. 

This  term  is  a  sort  of  catchall  for  a  number  of  skin  diseases  of 
diverse  etiology,  but  having  for  their  common  symptoms  an  in- 
tensely itching  dermatitis.  It  is  a  disease  of  the  tropics,  and  can 
often  be  seen  on  returning  soldiers.  The  state  of  California  takes 
cognizance  of  it,  making  it  a  reportable  disease.     In  military  prac- 


TPIE   RINGWORM    GROUP.  181 

tice,  where  it  is  most  common,  it  is  not  isolated,  but  care  is  exer- 
cised to  prevent  contagion,  either  mediate  or  direct.  The  exciting 
cause  is  probably  an  infection  by  one  or  more  of  the  fungi  described 
under  tinea  and  by  related  organisms.  The  disease  in  the  tropics 
is  rather  inveterate,  coming  out  particularly  on  those  parts  of  the 
body  which  are  apt  to  be  irritated  by  the  clothing.  The  sears  left 
by  the  dermatitis  are  apt  to  be  pigmented. 


CHAPTER  XVIII. 
THE   CONJUNCTIVITIS  GROUP. 

These  diseases  are  of  the  gravest  importance  to  the  public,  since 
loss  of  sight  is  not  only  a  calamity  to  the  individual,  but  a  loss  to 
society  in  that  an  actual  or  potential  wage-earner  is  deprived  of 
the  opportunity  to  make  a  living,  and  is  thro^vn  as  a  burden  on 
his  family  or  the  municipality. 

Therefore,  the  health  officer  is  in  duty  bound  to  aid  in  every 
way  the  suppression  of  the  spread  of  infectious  eye-diseases,  resort- 
ing if  need  be  to  drastic  measures  of  quarantine  under  the  general 
authority  of  his  commission  in  the  absence  of  specific  legislation. 

TRACHOMA. 

Synonyms. — Granular  Conjunctivitis;  Egyptian  Ophthalmia; 
Military  Ophthalmia. 

Definition. — An  infectious  disease  of  the  eye,  chronic  in  type, 
characterized  by  small  oval  masses  in  the  palpebral  conjunctiva, 
and  by  secondary  changes  in  lids,  conjunctiva  and  globe. 

Distribution. — Trachoma  is  a  world-wide  disease,  formerly 
thought  to  be  rare  in  the  United  States,  but  now  laiown  to  be  very 
common.  Sanitary  surveys  of  such  parts  of  the  country  as  have 
been  completed  have  shown  it  almost  everywhere,  the  most  striking 
result  being  in  the  eastern  counties  of  Kentucky,  among  an  almost 
purely  native  American  population,  where  the  survey  indicates  a 
total  of  33,000  cases. 

Onset. — There  are  three  forms  of  onset : 

1.  The  granules  develop  without  discomfort,  there  being  little 
mucous  secretion,  only  slight  lacrymation,  and  slight  thickening 
of  the  lids.  The  ocular  conjunctiva  is  not  reddened  and  the  cornea 
is  not  involved. 

2.  The  common  form  of  onset.  There  is  pain  in  the  eyelids 
which  feel  hot  and  rough  to  the  patient.  The  irritation,  lacryma- 
tion, and  after  a  few  days  the  mucopurulent  secretion,  are  much 
more  than  in  the  first  form.     On  turning  the  lids,  the  conjunctiva 

182 


THE    CONJUNCTIVITIS   GROUP.  183 

is  found  to  be  much  reddened  and  thickened,  and  after  2  to  4  weeks 
from  the  beginning,  granules  may  be  seen  over  the  tarsal  cartilages 
and  sometimes  further  back.  The  swelling  of  the  conjunctiva  may 
be  enough  to  mask  the  granules,  and  they  may  become  visible  only 
after  the  acute  condition  has  subsided.  The  glands  in  front  of  the 
ear  are  enlarged. 

3.  This  form  is  fortunately  uncommon,  but  is  seen  in  young  and 
middle-aged  adults.  The  onset  is  rapid,  with  burning  and  scratch- 
ing of  the  lids,  and  after  a  day  or  two  there  is  a  marked  lacryma- 
tion,  followed  by  a  mucopurulent  or  even  bloody  discharge.  The 
conjunctiva  is  hypertrophied  and  the  granules  are  confluent.  The 
ball  is  much  injected  and  corneal  involvement  begins  early. 
The  preauricular  glands  and  even  the  submaxillary  lymphatics  may 
be  swollen. 

Second  Stage. — After  the  first  stage  has  lasted  from  6  weeks  to 
a  year,  the  second  stage  begins,  with  the  coalescence  of  the  granules 
which  then  go  on  to  cicatrization.  The  cul-de-sacs  of  the  conjunc- 
tiva become  shallow,  the  tarsal  cartilages  shorter,  narrower  and 
more  curved.  The  corneal  epithelium  is  destroyed  by  the  rubbing 
of  the  roughened  lids.  Vascular  pannus  destroys  the  clearness  of 
the  cornea  forever.  Secondary  infections  become  engrafted,  the 
eyelids  are  turned  in  by  the  contraction  of  the  scars  and  the  lashes 
rub  the  balls. 

Third  Stage. — After  years  of  the  second  stage,  the  third  stage 
appears.  The  cornea  is  entirely  opaque  and  only  light  perception 
remains.  The  conjunctiva  is  entirely  destroyed  and  the  area  for- 
merly occupied  by  it  much  contracted.  The  cornea  is  dry  and 
harsh,  and  pale  in  color. 

Isolation. — Isolation  must  be  enforced,  and  the  utmost  care  taken 
that  all  towels  and  toilet  articles  used  by  the  patient  are  disinfected. 
Attendants  must  thoroughly  disinfect  their  hands  by  one  of  the 
standard  methods.  This  disease  is  an  absolute  bar  to  entrance  into 
the  United  States  by  prospective  immigrants. 

MUCOPURULENT  CONJUNCTIVITIS. 

Two  forms  of  micro-organism,  the  Koch-Weeks  bacillus  and  the 
Morax-Axenfeld  bacillus,  cause  somewhat  differing  forms  of  muco- 
purulent conjunctivitis.  Both  forms  are  characterized  by  lacry- 
mation  and  the  presence  of  mucus  and  pus  in  the  eyes.  Children 
having  them  should  be  excluded  from  school  and  isolated  if  in 


184  PRACTICAL   SANITATION. 

institutions.     Care  sliould  be  taken  that  they  are  not  transmitted 
by  unclean  hands,  towels,  or  basins. 

GONORRHEAL  CONJUNCTIVITIS. 

This  dangerous  disease  is  due  to  infection  with  the  gonococcus. 

Incubation. — 24  to  36  hours. 

Acute  Stage. — For  the  first  24  hours  the  eyes  are  reddened  and 
the  flow  of  tears  increased ;  as  the  period  draws  to  a  close  the  lids 
are  much  swollen  and  injected  and  the  secretion  becomes  muco- 
purulent, sometimes  bloody  and  always  mixed  with  the  tears.  The 
eyes  burn  and  feel  gritty  to  the  patient,  and  pain  is  felt  in  the  ball 
on  pressure.  In  48  to  72  hours  longer,  the  height  of  the  inflam- 
mation is  reached;  the  swelling  of  the  lids  is  enormous,  the  patient 
being  unable  to  open  the  lids  and  the  surgeon  able  to  do  so  only 
with  difficulty.  The  conjunctiva  of  the  lids  is  thickened  and  vel- 
vety, while  that  of  the  balls  is  swollen.  Chemosis  is  marked  and 
ecchymoses  appear  here  and  there  on  the  ball.  The  pus  is  yellow, 
thin,  and  streams  from  the  eyes. 

Subacute  Stage. — After  5  to  8  days  the  swelling  of  the  lids  sub- 
sides and  the  venous  congestion  disappears.  The  pain  moderates, 
and  after  2  or  3  weeks  convalescence  may  be  established,  or  a  chronic 
condition  lasting  for  months  may  supervene. 

Complications. — About  one-third  of  the  cases  have  involvement 
of  the  cornea  with  varying  results.  Complete  restoration  may 
occur  or  there  may  be  sloughing  with  entire  loss  of  vision.  Iritis, 
irido-choroiditis,  or  panophthalmitis,  with  loss  of  the  eye,  may  also 
occur. 

Prophylaxis. — All  patients  having  gonorrhea  or  gleet  must  be 
warned  of  this  danger.  The  disease  is  carried  like  other  forms  of 
conjunctivitis  and  the  same  measures  are  effective  in  its  prevention. 

OPHTHALMIA  NEONATORUM. 

This  very  dangerous  disease  is  a  purulent  conjunctivitis  due 
usually  to  the  gonococcus,  but  sometimes  to  other  pus  organisms, 
which  is  contracted  generally  during  birth,  but  more  rarely  in  utero. 
It  begins  ordinarily  on  the  second  day  after  birth,  but  sometimes 
a  few  days  later.  It  is  similar  in  evolution  to  gonorrheal  conjunc- 
tivitis and  its  .spread  to  others  is  to  be  prevented  in  the  same  way. 
Its  prevention  in  the  new-born  is  a  matter  of  the  greatest  simplicity, 
being  simply  a  cleansing  of  the  eyes  with  a  physiological  salt  solu- 


THE    CONJITNCTIVITIS    GROUP.  185 

tiou,  a  saturated  solution  of  boric  acid,  or  merely  boiled  water, 
immediately  after  birth,  and  the  instillation  into  each  eye  of  1  or  2 
drops  of  silver  nitrate  solution,  2  per  cent  (10  grains  to  the  ounce). 
This  must  never  be  omitted,  even  in  the  case  of  those  who  are  pre- 
sumably free  from  infection,  because  its  omission  tends  to  make  the 
use  of  the  solution  invidious  when  really  required. 

Many  states  require  ophthalmia  neonatorum  to  be  reported,  and 
some  require  a  notation  on  the  birth  certificate  that  the  necessary 
precautions  have  been  taken.  Since  a  very  high  percentage  of  the 
hopeless  blindness  of  children,  variously  estimated  at  from  80  to  90 
per  cent  is  caused  by  this  disease,  no  precautions  are  too  strict. 
The  sanitarian  should  fulfill  his  duty  by  seeing  that  all  such  regu- 
lations are  enforced. 


CHAPTER  XIX. 

THE  ANIMAL  PARASITES. 

Yery  many  species  of  animals  above  the  protozoa,  which  are 
treated  separately,  are  parasitic  in  man.  Only  those  will  be  here 
mentioned  which  are  found  in  the  United  States,  and  are  either 
known  to  be  pathogenic  in  themselves  or  capable  of  acting  as  dis- 
ease carriers.  The  space  which  can  be  allotted  to  this  subject  is 
insufficient  to  allow  more  than  the  most  cursory  review  of  the  sub- 
ject.^ 

FLUKES. 

Parag-onimus  (Distoma)  Westermanni. — This  worm  is  the  cause 
of  a  peculiar  lung  disease,  characterized  by  a  chronic  cough,  with 
rusty  sputum  and  occasional  hemorrhages,  usually  light  but  some- 
times severe.  The  parasite  is  8  to  16  mm.  in  length,  with  a  breadth 
of  half  the  length,  is  a  native  of  the  eastern  coast  of  Asia,  and  is 
sometimes  imported  into  the  United  States.  It  is  probably  also  a 
native  infection  of  the  cat,  dog  and  hog  in  this  country,  and  the 
method  by  which  man  is  infected  is  not  known.  The  ova  of 
the  fluke  are  to  be  found  in  the  sputum  and  their  presence  verifies  the 
diagnosis. 

Fasciolidae  (The  Liver  Flukes). — Five  species  belonging  to  this 
family  and  representing  three  distinct  genera  are  known  to  occur  in 
man,  and  probably  all  of  them  are  to  be  found  in  this  country, 
either  by  original  infection  or  importation. 

Symptoms. — There  is  an  irregular,  intermittent  diarrhea,  usually 
with  blood.  The  liver  gradually  enlarges,  with  pain  and  inter- 
mittent jaundice.  There  is  little  fever.  After  2  or  3  years,  both 
ascites  and  anasarca  come  on,  with  anemia  and  persistent  diarrhea. 
Apparent  recovery  may  take  place,  but  relapse  occurs  and  the  pa- 
tient dies. 

This  is  a  disease  which  tends  to  attack  all  the  members  of  a  family, 

'  The  reader  who  wishes  to  study  these  parasites  exhaustively  is  referred  particularly 
to  Tyson,  whose  well  illustrated  chapter  on  the  subject  includes  not  only  clinical  but  fuU 
zoological  data. 

186 


THE   ANIMAL   PARASITES.  187 

and  particularly  the  young  children.  For  this  reason  it  is  well  to 
suspect  transmission  of  the  ova,  which  abound  in  the  stools,  on  dirty 
hands.  In  cases  which  have  developed,  nothing  can  be  done  ex- 
cept to  see  that,  by  proper  care  of  the  stools  and  persons,  it  is  not 
transmitted  to  others. 

TAPE-WORMS. 

The  tape-worms  have  a  two-cycle  existence,  the  adult  stage  being 
passed  in  man,  and  the  other  in  the  body  of  an  intermediate  host. 
The  two  commonest  forms  in  this  country  are  the  pork  tape-worm. 
Taenia  solium,  and  the  beef  tape-worm,  Tmiia  mediocanellata.  A 
description  of  these  species  will  be  omitted  here  since  they  are  fa- 
miliar to  all,  but  attention  is  called  to  the  immature  forms,  the 
cysticerci,  bladder- worms  or  measles,  dead- white  opaque  sacs  one- 
fourth  to  one-half  inch  in  diameter,  seen  in  the  muscle  and  other 
parts  of  beef  and  pork  carcasses.  Carcasses  containing  them  should 
be  condemned,  unless  thorough  cooking  can  be  assured.  Properly 
cooked,  there  is  no  objection  to  their  use. 

Another  tape-worm,  Bothryocephalus  latus,  the  broad  or  fish  tape- 
worm, formerly  supposed  to  be  confined  to  northern  Europe,  has 
been  found  to  affect  the  fish  in  the  Great  Lakes  which  were  appar- 
ently infected  through  sewage  containing  ova  from  the  stools  of  im- 
migrants from  the  originally  infected  districts.  Our  present 
methods  of  sewage  disposal  are  such  as  to  favor  the  wide-spread  dis- 
semination of  this  parasite,  were  it  not  for  the  fact  that  Americans 
usually  do  not  like  underdone  fish.  Unlike  other  tape-worms,  the 
Bothryocephalus  seems  at  times  to  cause  rather  marked  symptoms  of 
anemia. 

Generalized  cysticercus  infection  may  occur,  either  from  ova  of 
any  of  the  above  species  regurgitated  from  the  small  bowel  into 
the  stomach  in  individuals  harboring  an  adult  tape-worm,  or  by 
an  infection  from  the  ova  of  these  or  any  other  of  the  tape-worms 
which  may  have  been  accidentally  swallowed. 

ROUNDWORMS. 

Five  species  of  roundworms  are  of  importance:  the  common 
roundworm  {Ascaris  lumhricoides) ,  the  threadworm  {Oxywcis  ver- 
ndcularis),  and  the  two  hookworms  (Ankylostomum  diwdenale),  the 
European  species,  and  {Necator  americanus)  the  American  species, 
and  Tnchina  spiralis. 


188 


PRACTICAL   SANITATION. 


(    ) 


^ 


Fig.    3. 


lig.   4. 


Fig.  3. — Male  and  female  hookworms  {Necator  americanus) , 
natural  size. 

Fig.  4. — Greatly  enlarged  view  of  a  hookworm  shortly  after 
it    has    heen   hatched    from   the   egg. 

Fig.  .5. — Figure  of  a  worm  about  seven  days  old.  This  is 
the  so-called  "  encysted  stage "  and  is  the  stage  which 
enters  man. 


Fig.   5. 


THE   ANIMiiL   PARASITES.  189 

The  first  two  of  these  need  no  description,  as  they  are  familiar 
even  to  the  laity.  There  can  be  but  little  doubt  that  the  ordinary 
mode  of  infection  is  by  the  transfer  of  the  ova  on  unclean  hands 
or  by  contaminated  drinking  water.  For  this  reason  it  is  highly 
important  that  in  all  schools  facilities  should  be  provided  for  the 
children  to  cleanse  their  hands  after  going  to  the  toilet,  and  their 
use  should  be  enforced. 

The  adult  trichina  lives  in  the  small  intestine,  where  the  eggs  are 
deposited,  and  whence  the  young  make  their  way  immediately  after 
hatching  into  the  voluntary  muscles.  This  process  is  attended  with 
pain,  fever,  and  marked  increase  of  the  eosinophile  leucocytes. 

Trichinosis  is  absolutely  prevented  by  cooking  all  pork  until  well 
done.  Rats  and  hogs  are  the  animals  most  commonly  infected,  with 
cats  and  dogs  less  frequently.  Human  trichinosis  is  more  common 
than  is  usually  supposed,  having  been  found  by  H.  U.  "Williams,  of 
Buffalo,  in  27  out  of  505  unselected  autopsies,  a  percentage  of  5.3. 
It  is  not  sufficiently  common  as  a  cause  of  death  to  appear  in  the 
Census  reports  as  a  separate  item. 

The  European  hookworm  is  found  in  the  deep  mines  of  California 
and  perhaps  in  other  places,  where  it  has  been  brought  in  by  miners 
'who  have  become  infected  in  European  mines.  The  American  hook- 
worm is  found  in  all  the  Southern  States,  in  Cuba,  Porto  Rico  and 
tire  Philippines.  Both  forms  have  the  same  general  characteristics, 
the  males  being  one-half  inch  or  a  little  less  in  length,  and  the 
females  about  three-fourths  inch.  The  mouth  is  provided  with  a 
heavy  armature  of  sharp  teeth  by  which  to  lay  hold  of  the  intestinal 
mucosa,  and  the  gullet  is  a  strong  suctorial  organ  by  which  the 
blood  is  drawn  out.  The  eggs  are  75  mi.  by  40  mi.  in  the  American 
species  and  slightly  less  in  the  European  species. 

The  mode  of  infection  is  peculiar.  The  feces  of  an  infected  per- 
son being  deposited  in  a  warm,  moist  place,  the  eggs  hatch  out  the 
larval  worms,  which  immediately  fasten  themselves  on  the  skin  of 
any  person  exposed  to  them,  and  proceed  to  make  their  way  through 
the  skin  and  by  way  of  the  lymph  spaces  and  perhaps  the  blood 
vessels  to  the  intestine.  Burrowing  through  the  intestinal  wall, 
they  attach  themselves  to  the  mucosa,  and  soon  reach  the  adult 
stage.  Adult  worms  from  one  infection  may  live  as  long  as  10  to 
12  years. 

The  dermatitis  caused  by  the  passage  of  the  larvae  through  the 
skin  is  known  in  the  South  as  "ground  itch,"  "dew  itch,"  "toe 


190  PRACTICAL   SANITATION. 

itch"  and  so  on.  It  is  best  prevented,  together  with  the  subsequent 
hookworm  infection,  by  wearing  shoes,  since  the  larvae  are  unable 
to  make  their  way  through  the  leather. 

The  symptoms  of  hookworm  are  varied  and  serious.  The  skin 
is  dry  and  there  is  an  absence  of  perspiration ;  the  color  is  tallowy, 
and  from  a  waxy  white  to  a  dirty  yellow.  The  hair  is  dry,  coarse, 
and  often  scanty,  especially  on  the  body.  The  expression  is  stupid, 
often  so  markedly  as  to  permit  a  tentative  diagnosis  on  that  fact 
alone.  The  abdomen  is  swollen  and  prominent,  the  appetite  capri- 
cious and  often  there  is  a  morbid  desire  to  eat  the  most  unnatural 
things — clay,  chalk,  woolen  cloth  and  the  like.  Blood  may  or  may 
not  be  found  in  the  stools.  The  most  characteristic  as  well  as  the 
gravest  symptom  is  the  anemia,  which  is  often  profound,  the  red 
cells  running  sometimes  as  low  as  754,000,  and  in  other  cases  the 
hemoglobin  has  been  reported  as  low  as  8  per  cent.  In  the  usual 
run  of  severe  cases  the  red  cells  and  hemoglobin  will  be  reduced 
not  far  from  50  per  cent  on  the  average.  The  urinary  and  repro- 
ductive systems  of  the  patient  suffer  severely.  Menstruation  is 
established  late,  sometimes  as  late  as  20,  is  infrequent  and  scanty 
W'hen  it  does  occur.  In  the  male,  sterility  and  impotence  are  not 
uncommon,  and  in  the  female,  miscarriage,  still-birth  and  sterility 
are  very  usual. 

The  age  of  the  patients  with  ankylostomiasis  is  greater  than  that 
of  those  with  American  hookworm  disease,  as  the  former  is  an  occu- 
pational disease  of  miners  and  clay-workers,  while  the  latter  is  a 
disease  of  the  open  country,  to  which  children  on  account  of  the 
habit  of  going  barefoot  are  more  exposed  than  adults.  Stiles '  1,470 
cases  show  nearly  60  per  cent  under  18.  The  following  very  clear 
directions  for  diagnosis,  prophylaxis  and  treatment  are  from 
Stiles.i 

Hookworm  Disease. 

Diagnosis. — 'llicrc!  are  tliree  methods  of  diagnosing  hookworm  disease — 
namely,  by  microscopic  examination  of  the  fecal  material  to  find  the  eggs; 
by  judging  the  symptoms;  and  by  experimental  treatment  and  finding  the 
expelled  worms  in  the  stools. 

Microscopic  Examination  of  feces. — It  is  rare  that  the  adult  worms  are 
seen  in  the  discharges  except  during  treatment,  but  the  stools  of  hookworm 
cases  contain  the  characteristic  eggs  of  the  parasite,  and  by  finding  these 
eggs  a  positive  diagnosis  can  easily  be  made.     The  Southern  state  boards  of 


*  Hookworm  Disease    (or  Ground-itch  Anemia).     Public  Health   Bulletin  No.   32,   Pub- 
lic Health  and  Marine  Hospital  Service.     Washington,  Government  Printing  Office,  1910. 


THE   ANIMAL   PARASITES.  191 

liealtli  and  the  Hj'gienic  Laboratory  of  the  United  States  Public  Health  and 
Marine-Hospital  Service  are  making  tliis  examination  free  of  charge. 

Ordinary  technique. — For  ordinary  purposes  the  following  technique  is 
sufficient:  Patients  are  instructed  to  furnish  about  half  an  ounce  of  their 
fresh  fecal  material.  A  small  portion  of  this  is  taken  up  on  the  flat  end  of 
a  toothpick  (using  a  separate  toothpick  for  each  specimen)  and  smeared  on 
a  slide  in  a  drop  of  water  (personally  I  prefer  the  2  by  3  inch  rather  than  the 
1  by  3  inch  slide;  and  in  hot  weather  or  when  the  feces  are  especially 
oflfensive,  trikresol  is  better  than  water)  ;  the  smear  should  be  uniform  and 
not  too  thick;  no  staining  or  drying  is  necessary;  a  cover  glass  (1  inch  square 
is  a  good  size)  is  placed  over  the  smear,  fluid  is  added  under  the  cover  if  neces- 
sary, or  drained  off  in  case  too  mucli  is  present,  and  the  prepJiration  is  ex- 
amined under  an  S-millimeter  (or  one-third  inch)  objective.  A  mechanical 
stage  is  unnecessary.  The  manipulation  of  the  slide  is  rendered  easier  if  it 
is  held  lengthwise  (if  a  1  by  3  slide  is  used)  rather  than  otherwise.  In  heavy 
infections  the  eggs  will  usually  be  found  on  the  first  slide,  but  at  least  ten 
such  preparations  should  be  examined  before  a  negative  opinion  is  expressed. 
It  takes  about  thirty  to  sixty  minutes  to  examine  ten  such  slides  properly. 

Usually  eggs  will  be  found  in  fresh  feces  in  the  4  to  8  cell  stage  (fig.  6). 
If  in  perfectly  fresh  specimens  eggs  are  found  in  the  32-cell  stage  there  is  a 
chance  that  another  parasite  {Tricliostrongylus)   is  present. 

If  free  embryos  are  present  in  the  fresh  feces  the  probability  is  that  the 
Cochin  China  worm    (Strongyloides  stercoralis)    is  present. 

The  mouth  cavity  of  the  hookworm  embryo  is  about  as  long  as  the  diameter 
of  the  embryo  at  the  posterior  end  of  mouth  cavity;  in  the  embryo  of 
Strongyloides  the  mouth  cavity  is  only  about  half  as  long  as  the  diameter 
of  the  embryo  at  the  posterior  end  of  the  mouth  cavity. 

If  pressure  is  exerted  on  the  slide,  the  outer  covering  of  Ascaris  eggs  may 
rupture,  and  the  beginner  might  possibly  confuse  these  with  hookworm  eggs. 
The  beginner  in  this  work  may  also  be  confused  by  various  vegetable  cells 
found  in  the  specimen,  which  he  mistakes  for  eggs,  or  by  plant  hairs,  which 
he  mistakes  for  embryos.  Strawberry  hairs,  especially,  are  mistaken  for 
hookworms  by  persons  not  familiar  with  this  class  of  work. 

Diagnosis  by  symptoms. — The  recognition  of  well-marked  cases  on  basis 
of  symptoms  presents  very  little  difficulty  to  one  who  is  thoroughly  familiar 
with  this  disease,  but  in  general  for  every  case  so  recognized,  one  to  several 
cases  will  be  in  doubt  or  will  entirely  escape  the  clinician  who  may  depend 
entirely  on  symptomatology. 

Given  a  patient  in  the  area  of  infection,  with  dry  hair,  dry  skin,  dilated 
pupil  or  with  unusual  tendency  to  dilatation,  with  tenderness  in  the  epi- 
gastric region,  continuing  toward  the  right  but  with  a  tendency  to  disappear 
toward  the  left,  with  winged  shoulder  blades,  shoulders  sloping  down  and 
forwar<!f,  slow  of  speech,  tallow-like  skin,  poorly  developed  in  general,  anemia, 
scant  pubic  and  axillary  hair,  a  delayed  type  of  menstruation,  and  a  history 
of  ground  itch,  especially'  if  several  such  persons  exist  in  the  same  family,  and 
diagnosis  is  practically  positive. 

Diagnosis  by  experimental  treatment.^As  the  state  boards  of  health  are 
making  diagnoses  free  of  charge,  there  is  little  if  any  reason  for  not  having 
a  microscopic   examination  made.     At  the  same  time  the  practical  difficulty 


192 


PRACTICAL   SANITATION. 


Fig.  6.-^Hookworm  eggs,  enormously  enlarged,  in  different  stages  of  development.  The 
series  ag  is  drawn  from  one  and  the  same  specimen,  at  different  intervals  from 
10.45  A.  M.  to  12.05  1».  M.,  and  shows  how  rapidly  the  development  takes  place. 
(After  Stiles.) 


THE   ANIMAL   PARASITES.  193 

must  bo  frcqupntly  faeed  that  many  rural  people  who  have  no  objection  to  a 
microscopi''  examination  of  their  sputum  and  urine  do  object  very  decidedly 
to  furnishing  samples  of  their  stools.  This  may  appear  incomprehensible,  but 
it  is  p.  factor  which  must  be  squarely  faced.  Again,  in  remote  rural  regions 
it  is  often  impracticable  to  make  several  trips  to  the  house  to  obtain  a  stool, 
and  it  is  often  impossible  to  induce  the  patient's  family  to  take  the  trouble 
(if  sending  a  stool  to  the  physician.  In  such  cases  almost  the  only  plan  to 
follow  is  to  institute  an  experimental  treatment  and  see  if  hookworms  are 
passed. 

Treatment. — The  fundamental  principle  underlying  the  treatment  of  hook- 
worm disease  is  the  same  as  that  which  underlies  the  treatment  of  all  other 
zooparasitic  diseases,  namely,  first  treat  the  parasite,  not  the  patient.  After 
the  parasite  is  treated,  attention  may  be  directed  to  treating  the  patient. 

Although  hookworm  disease  may  occur  in  persons  in  any  walk  of  life,  it 
is  particularly  among  the  poorer  classes  that  it  is  found,  and  the  average 
hookworm  patient  (children  excepted,  to  a  certain  extent)  can  not  afford  to 
lose  several  days'  wages  to  undergo  treatment.  It  is  therefore  frequently 
expedient  to  conduct  the  treatment  Saturday  evening  and  Sunday  morning. 
It  will  often  be  found  difficult  to  arouse  the  interest  of  a  community  in  regard 
to  the  presence  of  hookworm  disease  and  the  need  of  treatment.  This  can 
frequently  be  done,  however,  if  it  is  borne  in  mind  that  the  resulting  anemia 
is,  in  common  with  other  anemias,  a  frequent  cause  of  amenorrhea. 

Warning. — Recalling  that  primarily  we  are  to  treat  the  parasite,  not  the 
patient,  it  should  be  remembered  that  if  too  great  a  quantity  of  thymol  is 
absorbed  by  the  patient,  alarming  symptoms  and  even  death  may  occur. 
Accordingly,  the  patient  and  the  patient's  family  should  be  cai-efully  warned 
not  to  permit  the  patient  under  any  circumstances  to  have  on  the  Sunday 
during  which  the  treatment  is  given  any  food  or  drink  containing  alcohol, 
fats,  or  oil.  Patent  medicines  should  be  mentioned  in  particular,  because  of 
the  alcohol  many  of  them  contain,  and  even  milk  and  butter  should  be  for- 
bidden. I  know  of  one  case  of  serious  thymol  poisoning  which  followed 
promptly  after  the  patient  took  a  copious  drink  of  milk  the  day  thymol  was 
taken. 

Preliminary  treatment. — On  Saturday  evening  give  a  dose  of  Epsom  salts. 
The  reason  is  this:  The  hookworms  are  surrounded  by  more  or  less  mucus 
and  partially  digested  food.  Unless  this  is  removed,  the  thymol  may  not 
reach  the  parasites,  but  may  reach  the  patient,  and  this  is  contrary  to  Avhat 
is  desired,  as  the  thymol  is  intended  for  the  parasite,  not  the  patient. 

Thymol  treatment  on  Sunday. —  (1)  Position  of  patient:  Instruct  the 
patient  to  lie  on  his  right  side  immediately  before  taking  the  drug  and  to 
remain  in  that  position  for  at  least  half  an  hour  after.  The  reason  for  this 
is  that  many  of  these  patients  have  enlarged  stomachs,  and  if  they  lie  on 
their  right  side,  the  drug  has  the  benefit  of  gravity  in  passing  rapidly  from 
the  stomach  to  the  intestine;  but  if  any  other  position  is  assumed,  the  drug 
may  remain  in  the  dilated  cardiac  portion  of  the  stomach  for  some  hours  and 
result  in  considerable  complaint  on  the  part  of  the  patient  and  delay  of  the 
drug  in  reaching  the  worms.  It  is  best  for  the  patient  to  remain  in  bed 
until  after  10  o'clock  (see  next  paragraph). 


194  PRACTICAL   SANITATION. 

(2)  Time  of  dosage:  Tlie  time  of  giving  and  size  of  dose  may  be  arranged 
on  either  of  two  plans,  depending  on  existing  conditions. 

(a)  The  plan  usually  followed  is:  At  6  a.  m.,  one-half  of  the  total  dose 
of  thymol;  at  8  a.  m.,  one-half  of  the  total  dose  of  thymol;  at  10  i  a.  m.,  Epsom 
salts  (never  castor  oil) . 

(b)  If  the  case  is  an  especially  severe  one,  or  if  the  patient  has,  upon  the 
first  Sunday's  treatment,  complained  of  burning  or  other  effects  of  thymol, 
the  following  plan  is  adopted:  At  6  a.m.,  one-third  of  the  total  dose  of 
thymol;  at  7  a.m..  one-third  of  the  total  dose  of  thymol;  at  8  a.m.,  one-third 
of  the  total  dose  of  thymol  (if  unpleasant  symptoms,  as  a  sensation  of  severe 
burning  in  the  stomach,  have  appeared  this  third  dose  should  be  omitted)  ; 
at  10  1  a.  m.,  Epsom  salts   (never  castor  oil). 

(3)  Food:  No  food  is  allowed  until  after  the  10  o'clock  dose  of  Epsom 
salts,  but  the  patient  is  permitted  to  take  a  glass  or  so  of  water  after  the 
thymol,  if  he  desires. 

(4)  Thymol:  Finely  powdered  thymol  in  capsules,  preferably  in  5-grain 
capsules,  should  be  used.  A  recently  proposed  modification  in  the  dispensing 
of  the  drug  promises  excellent  results;  this  is  to  powder  finely  the  thymol  with 
an  equal  amount  of  sugar  of  milk  and  to  use  the  flat  capsule  (cachet)  instead 
of  the  cylindrical  capsule.  By  this  method,  the  packing  of  the  thymol,  some- 
times observed  when  the  cylindrical  capsule  is  used,  is  avoided. 

(5)  General  rule  as  to  age:  In  the  table  of  dosage  given  in  the  next 
paragraph,  the  maximum  dose  per  day  to  be  adopted  as  a  routine  is  given 
for  various  age  groups.  In  determining  the  dose,  however,  the  rule  should 
be  followed  of  taking  the  apparent  rather  than  the  real  age  and  of  not  hesi- 
tating to  cut  down  the  dose  even  lower  in  case  of  unusually  severe  cardiac 
symptoms  or  other  unfavorable  conditions.  Thus  for  a  boy  16  years  old, 
who  appears  to  be  only  12  years  old,  or  in  whom  the  anemia  is  especially 
marked,  resulting  in  severe  cardiac  symptoms,  the  quantity  of  thymol  should 
be  reduced  to  the  12  or  even  the  8-year  dose.  Some  authors  give  the  impres- 
sion that  it  is  useless  to  give  thymol  for  this  disease  unless  the  full  dose  is 
administered.     This  view  is  not  in  harmony  with  my  experience. 

(6)  Size  of  dose:  The  following  doses  represent  the  maximums  amount 
to  be  used  during  one  day's  treatment  for  the  age  groups  in  question.  This 
is  practically  the  same  table  that  the  Porto  Rican  Commission  has  been 
using: 

Grains 

Under  5  years  old 7^ 

From  5  to  9  years  old 15 

From  10  to  14  years  old 30 

From  15  to  19  years  old 45 

From  20  to  59  years  old  60 

Above   60  years   old 30  to  45 

Total  dose,  to  be  divided  as  indicated  in  paragraph   (2). 

'  Some  physicians  prefer  to  allow  a  long;er  time  (six  to  eight  hours)  to  elapse  between 
the  last  dose  of  thymol  and  the  Epsom  salts.  If  this  plan  is  followed,  it  is  wise  to  keep 
the  patient  under  rather  close  observation. 

-  Some  physicians  use  larger  doses,  but  the  doses  here  given  seem  to  be  large  enough. 


THE   ANIMAL   PARASITES.  195 

Repetition  of  treatment. — The  foregoing  treatment  is  repeated  once  a 
week,  preliminary  treatment  Saturday  evening  and  thymol  on  Sunday  morn- 
ing, until  the  patient  is  discharged. 

Duration  of  treatment. — To  recognize  whether  the  parasites  are  all  ex- 
pelled, and  therefore  to  determine  when  to  end  the  thymol  treatment,  either  of 
two  plans  may  be  adopted,  namely : 

(a)  Microscopic  examination :  On  Saturday  morning  make  10  microscopic 
preparations  of  a  fresh  stool,  or  test  the  stool  by  the  Bass  method.  If  eggs 
are  still  present,  repeat  the  treatment;  if  eggs  are  not  found,  discontinue  the 
thymol.  It  takes  about  thirty  to  sixty  minutes  to  make  this  examination  of 
10  slides  thoroughly. 

(b)  Cheese-cloth  method:  A  much  easier  way  of  recognizing  tlie  completion 
of  the  treatment,  and  for  practical  results  nearly  as  satisfactory  as  the  micro- 
scopic examination,  is  the  following:  Instruct  the  patient  to  wash  all  of 
his  stools  Sunday  and  Monday  through  a  cheese  cloth  and  to  keep  the  cheese 
cloth  moist  and  bring  it  to  the  oflRce  on  Monday.  While  the  fecal  material  will 
wash  through,  the  worms  will  be  retained  in  the  cloth.  Continue  treatment 
as  long  as  worms  are  found  in  the  cheese  cloth. 

Oil  of  Chenopodium. — This  drug,  long  used  in  American  medicine 
as  "oil  of  wormseed"  against  the  roundworm,  has  lately  come  into 
prominence  in  Europe  as  a  remedy  for  hookworm.  It  is  much  less 
toxic  than  thymol,  fifty  years'  use  of  the  drug  showing  only  12 
cases  of  fatal  poisoning;  it  is  not  unpleasant  and  does  not  require 
fats  to  be  eliminated  from  the  diet.  It  is  a  paralyzant  to  the  worm 
and  when  absorbed  is  narcotic  to  the  human  subject.  It  is  given 
in  the  following  dosage :  6  to  8  years,  8  drops ;  9  to  10  years,  10 
drops;  11  to  16  years,  12  drops;  over  16  years,  12  to  16  drops 
(Gockel).  This  is  followed  in  2  and  4  hours  by  a  similar  dosage, 
and  in  another  2  hours  by  a  large  dose  of  castor  oil.  In  case  symp- 
toms of  poisoning  such  as  drowsiness  supervene,  the  drug  is  with- 
drawn, active  purgation  begun,  and  hot  strong  coffee  given  by 
mouth  or  rectum. 

As  thymol  has  been  rendered  scarce  by  the  European  war,  the 
use  of  this  drug  will  probably  increase,  particularly  as  it  is  decid- 
edly more  effective. 

An  additional  roundworm  disease  is  filariasis,  which  is  an  infec- 
tion with  one  of  three  kinds  of  microscopic  worms  belonging  to  the 
genus  Filana.  This  disease  is  at  present  tropical  only,  but  is  known 
to  be  conveyed  by  mosquitoes  of  the  genus  Culex,  and  may  possibly  at 
some  future  time  become  naturalized  in  this  country. 


196 


PRACTICAL   SANITATION. 


Fig.  7. — -Bedbug  {Cimcx  lectulariiis)  :  a,  Adult  female,  gorged  with  blood;  b,  same  from 
below;  c,  rudimentary  wing  pad;  d,  mouth  parts;  a,  b,  much  enlarged;  c,  d,  highly 
magnified. 


Fig.  8. — Bedbug  (Cimex  lectularius)  :  Egg  and  newly  hatched  larva,  a,  larva  from 
below;  b,  larva  from  above;  c,  claw;  d,  egg;  e,  hair  or  spine  of  larva.  Greatly 
enlarged,  natural  size  of  larva  and  egg  indicated  by  hair  lines. 


y/  f^ 


Fig.  9. — Bedbug  (Cimex  lectularius):  a,  larval  skin  shed  at  first  molt;  b,  second  larval 
stage  taken  immediately  after  emerging  from  a;  c,  same  after  first  meal,  distended 
with  blood.      Greatly  enlarged. 

(From  Circular  No.  47,  Revised  Edition,  U.  S.  Dep't  of  Agriculture.) 


THE   ANIMAL   PARASITES.  197 

ITCH  INSECT. 

Sarcopies  (Acarus)  scabiei,  the  Itch  insect,  is  an  arachnid  insect, 
parasitic  in  man,  which  produces  most  distressing  and  troublesome 
eruptions  of  the  skin.  The  male  is  one-fourth  mm.  in  length  and 
one-fifth  mm.  in  breadth.  The  female  is  pearly  white  and  can  be 
seen  with  the  naked  eye.  The  insect  lives  in  a  burrow  a  little  less 
than  one-half  inch  in  length  which  it  makes  for  itself  in  the  epi- 
dermis. The  female  lives  at  the  end  of  tliis  burrow.  The  male  is 
seldom  seen.  The  favorite  sites  for  its  attacks  are  the  folds  of  skin 
between  the  fingers  and  toes,  on  the  backs  of  the  hands,  the  axilla 
and  front  of  the  abdomen.  The  infection  may,  however,  cover  prac- 
tically the  whole  body. 

The  lesions  are  very  numerous,  and  are  partly  a  result  of  scratch- 
ing. They  are  generally  papular  or  vesicular  but  in  children  may 
resemble  ecthyma.  The  burrows  may  be  destroyed  by  the  scratch- 
ing, but  the  diagnosis  is  rarely  troublesome. 

Children  infected  with  this  disease  must  be  excluded  from  school 
until  entirely  well. 

TICKS. 

These  insects  are  familiar  to  all  and  require  no  description.  They 
are  here  mentioned  for  the  reason  that  two  varieties  of  African 
spirillum  fever  and  the  Rocky  Mountain  tick  fever  of  the  American 
Northwest  are  known  to  be  carried  by  them.  Determined  action 
has  been  taken  to  rid  the  last  named  region  of  ticks,  with  a  view  to 
controlling  this  fatal  and  little-understood  disease.  It  should  here 
be  noted  that  the  Texas  fever  of  cattle,  which  is  a  protozoal  infec- 
tion, was  the  first  disease  of  either  man  or  animals  definitely  proved 
to  be  insect-borne. 

LICE. 

Three  varieties  of  lice,  the  head  louse  {Pedtculus  capitis),  the 
body  louse  (P.  corpons)  and  the  crab  louse  {Phtliirius  pubis)  are 
parasitic  in  man.  For  the  head  louse,  repeated  saturations  of  the 
hair  in  coal  oil  are  efficacious.  For  the  body  louse,  boiling  all  cloth- 
ing or  exposing  it  to  dry  heat  for  several  hours  at  a  temperature 
just  short  of  scorching  is  efficacious.  A  small  amount  of  mercurial 
or  white  precipitate  ointment  applied  to  the  parts  of  the  body  where 
the  hair  is  long,  together  with  a  clipping  of  these  hairs  if  nits  ad- 


198  PRACTICAL   SANITATION. 

here  to  them,  A\dll  destroy  these  insects.  Pyrethriim  ("insect 
powder")  is  recommended  as  harmless  and  efficient.  Crab  lice  may 
be  destroyed  in  the  same  way.  Lice  are  not  only  annoying  in  insti- 
tutional sanitation,  bnt  are  the  only  certainly  known  carriers  of 
typhus  and  relapsing  fevers. 

BEDBUGS. 

These  insects  require  no  description.  They  are  carriers  of  trop- 
ical splenomegaly,  and  are  also  suspected  of  carrying  relapsing 
fever  and  typhus,  although  this  is  not  yet  proved.  They  are  very 
annoying  in  institutions,  and  are  best  destroyed  by  sulphur  fumiga- 
tion, steam  sterilization  of  bedding,  and  the  use  of  coal  oil  or  corro- 
sive sublimate  solution  one  per  cent  in  all  cracks  and  possible 
breeding  places.  This  may  be  applied  with  an  atomizer.  Iron  bed- 
steads are  less  apt  to  afford  breeding  places  for  these  pests,  but  may 
harbor  them  nevertheless. 

FLEAS. 

These  irritating  insects  are  not  true  parasites,  since  they  breed 
in  dirt  and  filth,  and  attack  man  and  other  animals  only  inciden- 
tally. They  may  be  driven  off  by  the  use  of  coal  oil  on  floors,  etc., 
or  turpentine  and  other  essential  oils,  or  pyrethrum  powder.  They 
may  be  trapped  by  putting  a  small  piece  of  raw  meat  into  a  saucer 
containing  a  small  quantity  of  coal  oil. 

Fleas  are  the  ordinary  carriers  of  plague  from  rodents  to  man, 
and  it  is  very  likely  that  otherwise  unexplainable  cases  of  ringworm 
and  like  parasitic  skin  diseases  are  secondary  to  flea  bites. 


PART  II. 
GENERAL  SANITATION 


CHAPTER  XX. 

THE  ORGANIZATION  OF  THE  SANITARY  SERVICE. 

The  military  ideal  is  the  highest  for  the  sanitary  service.  It 
presupposes  a  responsible  head  with  subordinates,  each  responsible 
for  his  own  portion  of  the  work,  appointed  after  searching  examina- 
tion, subject  to  frequent  inspections  as  to  his  continuing  zeal,  ability, 
and  efficiency.  Such  a  body  values  highest  its  integrity,  its  devo- 
tion to  truth,  its  courage,  its  prompt  obedience  to  orders  and  its 
good  name.  Its  whole  purpose  is  the  faithful  performance  of  study, 
no  matter  at  what  personal  cost.  These  high  aims  come  near  to  per- 
fect realization  in  the  Public  Health  Service,  and  on  this  model  the 
state  and  local  sanitary  services  might  well  be  formed. 

Such  an  edifice  must  be  built  on  four  corner  stones.  First,  ade- 
quate training.  Most  of  us  have  had  to  get  our  training  in  sanita- 
tion by  practising  on  the  community  after  appointment.  Such 
knowledge,  whether  acquired  in  formal  instruction  or  in  the  school 
of  experience,  must  be  tried  on  the  touchstone  of  competitive  exam- 
ination, due  weight  being  given  to  proved  ability  and  experience, 
in  order  that  the  best  material  may  be  selected.  Zeal  and  good 
intentions  count  for  much,  but  in  a  highly  technical  position  like 
that  of  the  sanitarian,  the  best  trained  man  is  none  too  good. 

Second,  full  time  duty.  In  a  few  of  our  larger  cities  the  sanita- 
tarian  is  already  required  to  relinquish  private  practice,  but  in 
practically  none  of  the  smaller  places  is  this  so.  Health  work  is  not 
incompatible  with  other  public  medical  work,  provided  there  is  suf- 
ficient time  for  the  duties  allotted.  The  British  Local  Government 
Board  permits  health  officers  to  act  also  as  school  medical  officers, 
police  surgeons,  public  vaccinators,  district  medical  officers,  work- 
house and  factory  surgeons,  and  superintendents  of  isolation  hos- 

199 


200  PRACTICAL   SANITATION. 

pitals.  All  of  these  are  public  or  quasi-public  positions,  and  may 
with  propriety'  be  looked  after  by  the  sanitarian,  but  private  prac- 
tice and  health  work  represent  too  many  conflicts  to  make  them  a 
desirable  combination,  as  every  experienced  health  officer  knows. 

Third,  a  tenure  of  office  dependent  only  on  the  proper  discharge 
of  his  duties.  The  care  of  the  people's  health  is  too  sacred  a  thing 
to  be  made  the  football  of  politics.  It  should  not  be  possible  to 
remove  a  sanitarian  because  he  has  made  some  politician  put  his 
filthy  tenements  or  his  dairy  into  proper  condition.  Removal 
should  be  predicated  only  upon  charges,  properly  sustained  before 
a  civil  service  board  or  a  court.  Then  and  then  only  will  the 
health  officer  be  free  to  do  his  duty  as  he  sees  it.  A  corollary  to 
this  is  the  filling  of  vacancies  in  the  higher  grades  after  due  exami- 
nation and  scrutiny  of  the  record  of  the  candidate. 

'Fourth,  a  proper  remuneration  for  work  that  is  full  of  responsi- 
bility and  sometimes  dangerous.  If  districts  are  too  small  to  sup- 
port a  man  on  full  time,  let  them  be  combined  till  they  are  large 
enough,  or  let  some  of  the  duties  mentioned  under  the  second  head 
be  attached  to  the  position.  Furthermore,  a  man  is  willing  to 
accept  less  money  for  his  work  if  he  feels  that  it  is  a  place  of  honor, 
of  secure  tenure,  and  a  stepping-stone  to  a  better.  There  are  few 
counties  in  the  older  settled  portions  of  the  country  which  could  not 
by  a  per  capita  appropriation  of  25  cents,  secure  the  entire  time  of 
an  excellent  sanitarian,  pay  for  his  clerical  and  outside  assistance, 
his  traveling  expenses  and  all  expenses  of  quarantine,  disinfection, 
laboratory  supplies  and  office  expenses,  with  a  balance  in  the  treas- 
ury at  the  end  of  the  year. 

Such  a  plan  is  not  chimerical,  since  it  is  in  use  in  Hawaii,  the 
Philippines,  in  many  of  the  larger  cities  of  this  country,  and  in 
practically  all  of  Europe  except  Russia  and  Turkey.  The  great 
difficulty  is  that  Americans  are  willing  to  do  for  the  inhabitants 
of  our  Island  possessions  and  the  Canal  Zone  what  they  are  too 
careless  to  do  for  their  families  and  themselves.  A  late  writer 
states  that  approximately  600,000  lives,  Avorth  when  capitalized,  to 
the  country,  more  than  a  billion  of  dollars,  are  lost  every  year  in 
the  United  States  from  preventable  disease.  With  an  organization 
such  as  is  here  outlined  in  every  State,  and  with  the  Public  Health 
Service,  or  better,  a  National  Department  of  Health  to  co-ordinate 
and  correlate  the  whole,  and  with  a  yearly  expenditure  of  $25,000,- 
000,  which  is  not  a  fourth  of  what  we  spend  on  either  the  Army  or 


THE  ORGANIZATION  OP  THE  SANITARY  SERVICE.  201 

Navy,  we  should  save  the  billion  of  money,  and  better  still  we  should 
save  the  lives. 

The  grave  defects  of  the  present  organization  of  most  health 
boards  are,  that  they  are  unnecessarily  cumbersome  and  that  they 
tend  to  too  much  division  of  responsibility.  Many  of  them  are 
composed  wholly  or  in  part  of  laymen,  who  are  totally  unlearned  in 
sanitary  matters,  and  have  neither  the  time  nor  opportunity  to  ac- 
quaint themselves  with  the  subject.  The  services  of  the  laymen 
who  recognize  their  limitations,  but  give  their  time  and  efforts  to 
the  public  health  in  default  of  more  expert  assistance,  are  not  to 
be  decried,  and  the  public  has  had  abundant  reason  to  be  grateful 
to  them.  Nevertheless,  it  is  no  more  reasonable  to  expect  a  banker, 
a  carpenter  or  a  lawyer  to  understand  sanitation  than  it  is  to  ex- 
pect a  health  officer  to  build  a  house,  try  a  case  in  court  or  run  a 
bank.  "When  the  city  or  the  county  desires  to  put  up  a  public 
building,  the  plans  are  drawn  by  an  architect;  they  are  not  pre- 
pared by  the  local  jeweler  or  the  superintendent  of  schools. 

Then,  too,  lay  health  boards  usually  feel  that  health  matters  are 
best  left  in  the  hands  of  one  more  expert  than  themselves,  and 
either  by  resolution  or  informally  delegate  their  authority  to  the 
medical  man  on  the  board.  If  active,  lay  health  boards  are  prone 
to  interfere  with  energetic  health  campaigns,  either  on  the  score  of 
expense  or  because  it  was  not  the  way  of  the  fathers.  Neither  way 
is  desirable. 

The  single  health  officer,  or  health  commissioner,  as  he  is  called 
in  Indiana,  has  no  board  to  hide  behind.  The  responsibility  is  all 
his,  and  the  credit  or  blame  likewise.  He  may  seek  advice  within 
or  without  the  ranks  of  the  profession,  or  of  his  State  Board,  but 
within  his  delegated  powers  he  is  supreme,  and  only  liable  for  an 
unreasonable  use  of  his  office.  Experience  has  shown  that  this  sys- 
tem works  well.  Within  his  county  he  has  co-ordinate  authority 
with  the  State  Board  of  Health,  and  an  order  from  him  is  just  as 
binding  for  the  condemnation  of  an  unsanitary  schoolhouse  or  the 
settlement  of  a  moot  point  in  sanitation.  This  leads  to  celerity  of 
action  in  handling  health  matters,  but  since  the  responsibility 
cannot  be  delegated  nor  shifted,  makes  also  for  judicial  care  in  the 
execution  of  his  duties. 


CHAPTER  XXI. 

LOCAL  RECORDS,  AND  STATISTICAL  METHODS. 

Purposes. — A  complete  record  of  Births,  Deaths,  and  Infectious 
Diseases  should  be  kept  in  the  office  of  every  local  health  officer  or 
Board  of  Health.  These  records  are  not  primarily  for  their  sta- 
tistical value,  since  the  central  statistical  authorities  in  all  regis- 
tration states  compile  the  statistics  from  the  originals  filed  with 
them.  These  are  promptly  published,  are  accurately  collated  by 
skilled  statistical  workers,  and  make  any  duplication  unnecessary 
except  perhaps  in  large  cities.  The  real  value  of  the  local  record 
is  legal.     The  birth  record  is  of  value : 

1.  To  prove  citizenship,  as  for  applicants  for  Government  or 
State  positions,  or  for  passports,  or  for  the  exercise  of  the  fran- 
chise. 

2.  To  prove  age,  as  for  children  desiring  to  enter  or  leave  school, 
or  exemption  from  child  labor  laws,  or  pension  as  soldiers'  orphans, 
or  admission  to  reform  schools  and  orphanages. 

3.  To  prove  descent,  as  in  inheritance  and  pension  matters,  and 
legitimacy. 

4.  From  a  genealogical  standpoint. 

The  death  record  is  important: 

1.  In  probate  affairs. 

2.  In  pension  matters. 

3.  To  the  genealogist. 

4.  To  the  family  physician,  and  actuary. 

The  record  of  infectious  diseases  is  also  valuable: 

1.  To  the  sanitarian  himself,  as  enabling  him  to  see  in  black 
and  white  what  portions  of  his  territory  are  most  defective  and 
what  progress  he  is  making. 

2.  To  the  economist. 

3.  To  the  school  authorities. 

4.  As  modifying  quarantine  and  allowing  the  release  of  im- 

munes. 

202 


LOCAL    RECORDS,    AND    STATISTICAL   METHODS.  203 

Records. — Records  of  Marriage  and  Divorce  are  sometimes  kept 
and  may  become  important  either  from  the  statistical  or  legal 
standpoint. 

Birth  and  Death  records  should  conform  as  nearly  as  possible  to 
the  standard  forms.  The  only  change  should  be  in  the  heading, 
in  which  the  name  of  the  city  or  county  may  be  printed  in  and  the 
words  "official  copy"  added. 

If  made  up  on  the  "loose-leaf"  plan,  these  records  are  continu- 
ously self-indexing,  and  when  a  sufficient  number  have  accumulated 
to  make  it  worth  while,  say  at  the  end  of  six  months  or  one  or  two 
years,  may  be  removed  from  the  file,  with  the  thumb  indexes  in 
place,  and  permanently  bound.  Records  of  this  kind  may  be  made 
on  an  ordinary  typewriter,  with  a  great  gain  in  legibility.  For 
this  plan  two  things  are  requisite :  a  lock  file  or  lock  binder  and 
printing  on  one  side  of  certificate  only,  since  only  one  face  can  be 
indexed. 

This  method  may  be  modified  by  printing  on  both  sides  of  the 
blank  and  using  an  ordinary  index,  either  folio  or  card.  This 
second  plan  admits  of  the  use  of  a  serial  number,  which  is  not  al- 
lowed by  the  first,  until  just  before  binding,  but  makes  necessary 
the  use  of  the  index. 

Large  folio  records  are  also  often  used,  but  are  less  desirable  as 
they  require  either  the  use  of  longhand  or  of  an  expensive  book 
typewriter  in  copying. 

Indexes. — Indexes  are  of  two  kinds,  book  and  card.  The  book 
indexes  are  again  divided  into  bound  and  loose-leaf.  The  bound 
indexes  are  of  least  value,  since  in  small  communities  there  will  be 
an  abnormal  preponderance  of  one  or  more  index  letters  which  will 
fill  up  much  more  rapidly  than  others  and  either  require  transfers 
or  put  the  book  out  of  use  when  it  is  not  half  full.  Under  the 
loose-leaf  system,  additional  pages  may  be  added  to  take  care  of 
such  a  condition. 

A  properly  cared  for  card  system  will  index  to  any  desired  de- 
gree of  refinement,  and  the  typewriter  can  conveniently  be  used 
with  consequent  gain  in  convenience  and  legibility.  One  set  of 
boxes  is  sufficient  for  a  small  series  of  records  as  difl^erently  colored 
cards  may  be  used  for  births,  deaths,  marriages,  divorces  and  con- 
tagious diseases,  and  when  the  index  has  accumulated  to  sufficient 
size  these  may  be  redistributed  to  new  boxes. 

No  matter  how  the  index  is  kept  it  must  be  absolutely  complete 


204  PRACTICAL  SANITATION. 

or  it  will  lead  to  serious  mistakes.  If  cards  are  used  they  must 
be  properly  alphabetted  and  never  removed  from  the  drawer. 
Cards  which  are  locked  into  position  by  a  rod  passing  through  a 
hole  or  slot  are  more  satisfactory  for  this  reason. 

Serial  Numbers. — Serial  numbers  are  necessary  for  easy  refer- 
ence to  any  set  of  records.  They  are  of  two  kinds.  One  is  used 
for  originals  sent  to  the  central  statistical  office,  and  begins  with 
the  year  at  1  and  runs  consecutively  through  the  year.  The  second 
is  a  number  which  begins  with  the  first  record  and  runs  consecu- 
tively until  the  number  becomes  unwieldy,  beginning  again  at  1 
with  a  check  letter  or  number  for  a  new  series.  The  first  form  is 
obligatory.  The  second  is  optional,  but  of  great  convenience  in 
connection  with  card  or  other  general  index  systems. 

Infectious  Diseases. — The  record  of  infectious  diseases  is  most 
easily  kept  in  a  large  folio  with  one  line  to  an  entry,  extending 
across  both  pages.  The  headings  for  the  perpendicular  columns 
should  be:  Name  of  disease;  Name;  Address;  Age;  Sex;  Social 
condition;  Number  in  family;  School  attended;  Schools  attended 
by  other  children;  By  whom  reported;  Time  reported  (month,  day, 
hour)  ;  Quarantine  instituted  (month,  day,  hour)  ;  Disinfected 
(month,  day,  hour)  ;  By  whom  disinfected. 

These  headings  are  also  adaptable  to  the  loose-leaf  plan.  Addi- 
tional headings  might  be  used  for  Remarks,  under  which  details  of 
vaccination,  immunization,  and  antitoxin  furnished,  and  Result, 
giving  death  or  recovery. 

A  record  kept  on  this  plan  would  become  increasingly  more 
valuable,  and  could  be  depended  on  to  show  tuberculosis  and  typhoid 
infected  foci  beyond  cavil. 

Statistical  Methods. — A  short  account  of  the  principal  rules 
which  concern  the  health  officer  in  his  work  of  gathering  the 
material  for  the  statistician,  follows.  Those  who  are  desirous  of 
going  into  the  subject  more  deeply  for  themselves  will  receive 
invaluable  assistance  from  the  publications  of  the  Bureau  of  the 
Census.  ^ 

Still-Births. — Certificates  of  death  are  usually  required  for  still- 
births, and  if  the  cause  of  pre-natal  death  is  ascertainable  it  will 
be  recorded  in  the  same  way  as  for  deaths  on  the  certificate.  Still- 
births will  not  for  statistical  purposes  be  compiled  as  births  or 
deaths,  but  separately.  In  case  the  registrar  issues  mortality  re- 
ports from  his  office,  he  should  bear  this  in  mind,  otherwise  his 


LOCAL    RECORDS,    AND    STATISTICAL   METHODS.  205 

mortalitj'  rate  will  show  unduly  high.  The  fact  that  still-births 
are  excluded  should,  however,  be  stated  in  the  heading  or  in  a 
foot-note. 

Bulletins. —  {Rule  No.  13,  American  Public  Health  Associa- 
tion.)— Total  deaths  should  include  all  the  deaths  that  occurred  in 
the  given  area  during  the  period  stated  in  the  table,  and  no  others : 

(a)  A  weekly  bulletin  should  include  all  deaths  that  occurred 
during  the  week  ending  at  12  midnight,  Saturday,  and  no  others: 
Provided  that  in  order  to  secure  earlier  publication,  a  weekly  bulle- 
tin may  include  "deaths  reported"  up  to  any  time,  but  should 
definitely  state  that  fact. 

(b)  A  monthly  bulletin  should  include  all  deaths  that  occurred 
during  the  month  and  no  others. 

(c)  An  annual  report  should  include  all  deaths  that  occurred 
during  the  calendar  year  and  no  others. 

Standard  Tables.— (72 (<Ze  No.  44,  A.  P.  H.  A.)— Every  state  or 
city  registration  office  publishing  an  annual  (or  biennial)  report 
should  include  therein  a  table  showing  the  population  (as  estimated 
by  the  United  States  Census  Bureau  for  intercensal  years),  total 
number  of  births  exclusive  of  still-births,  total  number  of  deaths 
exclusive  of  still-births,  total  number  of  marriages,  total  number 
of  divorces  (providing  this  information  can  be  obtained),  for  each 
year  of  registration. 

Bule  No.  45. — It  is  desirable  that  the  corresponding  rates  be 
given,  but  the  primary  figures  should  be  presented  whether  it  is 
possible  to  present  rates  or  not. 

Bule  No.  46. — Notes  should  be  given  in  all  instances  where  dis- 
crepant figures  have  been  officially  printed  relative  to  returns  for 
any  year,  and  the  correct  figures  be  definitely  stated. 

Bide  No.  47. — ^Notes  should  be  given  on  changes  in  methods  of 
compiling  still-births,  and  a  correct  statement  of  still-births  should 
be  established  for  each  year,  on  the  basis  of  the  methods  approved. 
If  necessary,  re-examination  of  the  original  returns  should  be  made 
for  the  purpose  of  obtaining  comparable  figures. 

Population. — In  order  to  calculate  m.ortality  rates,  it  is  neces- 
sary to  have  an  approximate  idea  of  the  population  of  the  regis- 
tration area.  In  the  census  years,  this  is  not  difficult,  since  the 
figures  are  furnished  directly,  but  in  the  intercensal  years  it  be- 
comes a  matter  of  calculation.  In  communities  having  a  shifting 
population,  it  is  easiest,  and  perhaps  as  accurate  as  any  to  assume 


206  PRACTICAL  SANITATION. 

a  population  2i/2  times  the  number  of  children  shown  by  the  school 
enumeration. 

The  Census  Bureau  rule  is  much  more  complicated.  The  period 
from  June  1,  1900,  to  April  15,  1910,  is  llSi/s  months.  A  monthly 
increment  is  found  by  dividing  the  intercensal  increment  by  118.5. 
Two  and  one-half  times  this  monthly  increment  are  added  to  esti- 
mate the  population  on  July  1,  1910.  Then  12  times  the  monthly 
increase  will  be  added  to  this  estimated  midyear  population  of  1910, 
to  estimate  for  the  midyear  of  1911,  and  this  same  annual  increment 
of  12  times  the  monthly  increment  will  be  added  to  the  population 
for  1911  to  find  that  for  1912,  and  so  on  to  another  census  year. 

Assuming  that  the  census  of  1920  is  taken  on  April  15,  as  was 
the  last,  the  problem  will  then  be  the  very  simple  one  of  dividing 
the  increase  in  any  given  area  into  10  parts  and  adding  one  part 
for  each  succeeding  year. 

Both  of  these  census  methods  are  more  accurate  for  large  areas 
and  populations  than  for  small  communities.  Another  factor  to 
be  taken  into  consideration  with  them  is  the  considerable  augmenta- 
tions of  area  apt  to  take  place  in  ten  years  in  any  growing  city. 
Therefore,  unless  a  state  or  police  census  is  available,  the  sanitarian 
in  a  small  place  will  do  best  to  adopt  the  plan  of  multiplying  the 
school  census  by  2%  to  estimate  his  population,  particularly  as  these 
figures  are  usually  available  annually. 


CHAPTER  XXII. 
THE  BIRTH  RECORD. 

Importance. — Birth  records  are  of  prime  importance  in  vital 
statistics,  but  so  far  not  even  a  single  State  has  succeeded  in  reach- 
ing a  standard  of  report  of  90  per  cent  of  all  births,  which  is  neces- 
sary for  acceptance  in  the  registration  area.  Pennsylvania  has  a 
law  based  on  the  model  framed  by  the  Census  Bureau,  which  was 
passed  in  1910,  and  which  if  properly  enforced  will  make  her  a 
registration  state.  Indiana  has  a  rider  to  the  Ophthalmia  Neona- 
torum law,  passed  in  1911,  requiring  all  births  to  be  reported  to 
the  health  authorities,  who  have  charge  of  the  registration,  within 
36  hours.  The  great  difficulty  with  either  one  of  these  laws  is  that 
they  must  be  enforced  by  the  local  authorities,  who  are  busy  men, 
full  of  the  business  of  getting  a  living  outside  the  meagerly  paid 
health  department.  They  do  not  feel  like  prosecuting  a  fellow  phy- 
sician for  failing  to  report,  and  the  law  fails  of  its  purpose.  Both 
these  laws  are  as  yet  too  new  to  judge  their  efficiency,  and  it  is  to 
be  hoped  that  they  will  succeed  as  well  as  similar  laws  do  in  Euro- 
pean communities,  where  an  unregistered  birth  is  an  unheard-of 
thing. 

In  Chapter  XXI,  under  the  caption  of  Local  Records,  a  number 
of  reasons  are  given  for  the  careful  collection  and  recording  of 
birth  certificates,  which  for  brevity's  sake  will  not  be  repeated  here. 
Suffice  it  to  say,  that  experience  in  an  office  which  has  a  well-indexed 
set  of  records  extending  over  29  years,  and  comprises  some  13,000 
names  in  a  community  having  now  about  23,500  souls,  has  shown 
that  information  asked  for  is  not  to  be  found  in  half  the  cases. 

Checks. — This  condition  can  be  avoided  in  only  one  way,  which 
is  for  the  registrar  to  exercise  continual  vigilance.  In  well-to-do 
families,  the  birth,  especially  in  small  communities  is  reported  in 
the  papers.  These  must  be  scanned  for  notices  of  this  kind.  In 
poorer  families,  in  both  large  and  small  communities,  the  infant 
mortality  is  high.  Burials  are  fortunately  under  pretty  good  con- 
trol.    If  deaths  of  children  1  year  old  or  younger  are  investigated, 

207 


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208 


THIS   CERTIFICATE    MAY    BE    NEEDED    IN    COURT    SOME    DAY    TO    PROVE 

LEGITIMACY    OR    PARENTAGE,    TO    SECURE    INHERITANCE    OF 

PROPERTY    OR    INSURANCE    OR    PENSION 


REGISTRATION  LAW 


[Approved  March  9,  1907.] 


Section  1.  Be  it  enacted  by  the  General  Assembly  of  the  State  of  Indiana,  That  it 
shall  be  the  duty  of  all  physicians  and  midwives  in  the  state,  to  report  upon  blank  forms 
supplied  by  the  State  Board  of  Health,  all  deaths  and  births  that  may  occur  under  their 
supervision,  and  also  all  cases  of  contagious  and  infectious  diseases  which  may  occur 
under  their  supervision  and  which  are  listed  as  reportable  in  the  rules  of  the  State  Board 
of  Health. 

The  reports  of  deaths  and  cases  of  infectious  diseases  shall  be  made  immediately  and 
reports   of   births   within    twenty   days   after   their   occurrence.      ******* 

Penalty. — "Any  physician  or  midwife  refusing  or  neglecting  to  make  death,  birth 
and  infectious  or  contagious  disease  reports  as  herein  provided,  shall,  upon  conviction,  be 
fined  for  the  first  offense  in  any  sum  not  less  than  ten  or  more  than  fifty  dollars,  and  any 
physician  or  midwife  who  is  convicted  the  second  time  for  the  violation  of  any  of  the 
above  provisions  shall  be  fined  not  less  than  fifty  or  more  than  one  hundred  dollars,  and 
any  physician  or  midwife  who  is  convicted  the  third  time  for  the  violation  of  any  of 
the  above  provisions,  shall  be  fined  one  hundred  dollars.  Householders  and  others  made 
responsible  in  this  act  and  failing  to  report  as  herein  provided,  shall,  upon  conviction,  be 
fined  not  less  than  ten  or  more  than  fifty  dollars  for  each  offense." 

Rule  5  op  the  State  Board  op  Health. — Secretaries  of  all  Boards  of  Health 
shall  be  diligent  in  performing  all  of  their  duties  under  the  health  statutes  and  the  rules. 
They  shall  study  and  learn  the  said  statutes  and  rules ;  they  shall  keep  careful  sanitary 
and  hygienic  supervision  over  their  respective  jurisdictions ;  they  shall  carefully  collect 
and  record  certificates  of  deaths,  certificates  of  births  and  reports  of  infectious  diseases; 
they  shall  promptly  file  against  and  prosecute  any  physician,  midwife  or  householder  for 
failure  to  report  deaths,  births  and  infectious  diseases,  and  they  shall  also  file  against 
and  prosecute  any  person  violating  any  health  law  within  their  respective  jurisdiction. 
Any  Secretary  of  any  Board  of  Health  who  fails  to  fulfill  and  enforce  this  rule  will  be 
prosecuted  by  the  State  Board  of  Health,  according  to  the  statutes. 

DUTY    OF    PHYSICIANS    AND    MIDWIVES    ATTENDING     BIRTHS. 

The  attending  physician  or  midwife  is  required,  under  penalty  provided  in  the  law 
as  quoted  in  the  extract  above,  to  file  a  properly  made  out  certificate  of  birth  with  the 
health  olficer  having  jurisdiction  within  twenty  days  after  birth.  The  local  health  officer 
is  obliged,  under  penalty,  to  report  violations  of  this  requirement.  No  certificate  made 
out  in  lead  pencil  will  be  accepted.  PLEASE  WRITE  PLAINLY  AND  TAKE  PAINS 
TO  MAKE  A  CORRECT  STATEMENT  OF  THE  FACTS  REQUIRED  BY  LAW,  AS 
THE  RECORD  MAY  BECOME  OP  GREAT  LEGAL  AND  PERSONAL  IMPORTANCE. 

DUTY  OF  HEALTH  OFFICERS  AND  DEPUTIES. 

1.  Appoint  a  deputy  to  act  only  in  the  illness,  absence  or  other  disqualification  of 
the  health  officers  and  deputies. 

2.  E.xamine  each  Certificate  of  Birth  when  filed  by  the  physician,  midwife  or  other 
person  and  see  that  all  of  the  items  required  by  law  are  properly  filled  out.  If  absolutely 
impossible  to  ascertain  anv  fact,  the  space  should  be  filled  bv  the  word  "Unknown."  DO 
NOT  ACCEPT  A  CERTIFICATE  UNLESS  MADE  OUT  IN  INK  OR  INDELIBLE 
PENCIL,  UNDER  ANY  CIRCUMSTANCES.  A  still-birth  should  be  registered,  both  as 
a  birth  and  as  a  death. 

3.  Immediately  record  the  certificate  in  the  local  register,  numbering  it  in  order 
beginning  with  "No.  1"  for  the  first  birth  that  occurs  in  each  year.  ENTER  THE 
SAME  NUMBER  ON  THE  CERTIFICATE,  WITH  DATE  OF  FILING  IN  YOUR 
OFFICE  AND  YOUR  OFFICIAL   SIGNATURE. 

4.  If  christian  name  is  not  stated  in  original  return,  issue  a  "Supplemental  Re- 
port" blank  to  the  reporter,  and  record  when  returned. 

5.  Send  in  to  State  Board  of  Health,  all  Certificates  of  Birth  in  your  possession, 
when  making  your  report  of  deaths  on  the  FOURTH  (4th)  day  of  the  month,  except  only 
those  belonging  to  the  month  just  begun. 

Copies  of  the  law  and  blank  certificates  of  birth  will  be  supplied  by  local  Health 
Officers  or  by  the  State  Board  of  Health. 

209 


210  PRACTICAL   SANITATION. 

it  will  often  be  found  that  the  birth  has  never  been  reported.  Of 
course  both  checks  apply  more  or  less  to  all  classes  of  society,  but 
have  more  weight  in  the  divisions  above  cited.  When  such  dere- 
lictions are  found,  it  becomes  the  duty  of  the  registr^ir  to  file  infor- 
mation and  prosecute  the  offender.  Such  duties  are  unpleasant, 
but  if  done  without  fear  or  favor,  after  having  plainly  brought  the 
law  to  the  attention  of  all  who  may  be  affected  by  it,  one  or  two 
examples  are  sufficient  to  convert  the  most  recalcitrant,  and  the 
further  enforcement  of  the  law  gives  little  trouble. 

Certificates. — There  is  no  general  standard  birth  certificate  as 
yet  adopted,  and  the  very  complete  and  practical  certificate  of  the 
Indiana  State  Board  of  Health  is  here  presented  as  one  covering 
all  the  necessary  points  both  from  a  statistical  and  a  legal  point  of 
view. 

The  certificates  are  issued  on  requisition  to  all  health  officers,  who 
in  turn  put  them  into  the  hands  of  physicians  and  midwives.  They 
are  conveniently  bound  in  blocks  of  10,  and  are  composed  of  the 
certificate  proper  and  a  stub,  a  line  of  perforations  affording  easy 
separation.  The  certificate  is  6  inches  high  by  8  inches  wide,  and 
the  stub  6x4.  The  stub  contains  in  abbreviated  form  the  data  on 
the  certificate,  and  is  for  the  personal  record  of  the  physician.  If 
he  utilizes  the  back  of  the  stub,  he  has  sufficient  room  for  a  very 
good  clinical  record. 

Headings. — The  headings  of  this  birth  certificate  conform  to 
those  of  the  standard  death  certificate  with  the  exceptions  to  be 
noted. 

Name  of  Child. — The  name  of  the  child  is  frequently  not  to  be 
had  at  the  time  of  making  the  return,  and  provision  is  made  for 
a  supplementary  return  which  follows  the  original  through  the  local 
health  office,  where  the  name  is  added  to  the  record,  to  the  Division 
of  Vital  Statistics  of  the  State  Board  of  Health,  where  it  is  bound 
up  with  the  original.  As  the  check  number  is  the  same  on  both 
original  and  supplement,  the  identification  is  easy. 

Born  Alive? — This  query  answers  definitely  whether  or  not  the 
child  was  still-born.     The  registrar  must  see  that  it  is  answered. 

Sex. — This  is  occasionally  omitted  carelessly  by  the  physician, 
and  must  b(!  definitely  answered  as  it  is  never  safe  to  infer  it  from 
the  name. 

Plural  Births. — Two  headings,  "Twin,  Triplet  or  Other"  and 
''Number  in  order  of  birth,"  give  more  trouble  than  any  others. 


THE   BIRTH   RECORD.  211 

They  relate  exclusively  to  plural  births,  but  are  often  filled  in  for 
single  births.     Fortunately  this  gives  rise  to  no  confusion. 

Legitimate? — This  must  be  answered  by  yes  or  no. 

Date  of  Birth. — This  point  is  covered  by  two  different  headings 
which  must  agree,  one  in  the  body  of  the  certificate  and  the  other 
in  the  certificate  of  the  attending  physician  or  midwife. 

Occupation  op  Parents. — Space  is  given  for  the  occupation  of 
both  parents.  In  time  this  will  show  the  effect  of  various  occupa- 
tions of  the  parents  on  the  birth  rate,  and  when  collated  with  the 
mortality  statistics,  on  the  infantile  death-rate. 

Number  op  Child  op  This  Mother. — And  ''Number  now  living." 
The  questions  noted  in  the  last  paragraph  are  partly  answerable 
from  the  certificate  itself,  by  checking  the  answers  to  these  two 
questions. 

Ophthalmia  Neonatorum. — The  attendant  must  answer  on  the 
certificate  itself  whether  or  not  precautions  were  taken  against  oph- 
thalmia neonatorum.  The  fact  that  it  must  be  answered  yes  or. 
no,  and  that  failure  to  take  such  precautions  would  be  most  dama- 
ging in  case  of  infection,  has  a  great  tendency  to  prevent  neglect. 

File  Marks. — The  filing  and  recording  of  the  paper  must  be 
authenticated  by  the  signature  of  the  Health  Officer.  In  case  he 
adds  the  name  from  a  supplementary  report  which  reaches  him 
before  the  fourth  of  the  following  month,  he  also  certifies  to  that 
fact,  and  does  not  cumber  the  files  by  sending  in  the  supplement. 

Responsibility. — To  recapitulate :  The  essentials  of  a  successful 
law  for  recording  births  are :  responsibility  on  physician  or  midwife 
if  present  or  parents  if  birth  is  unattended ;  efficient  local  registrars ; 
a  central  authority  to  which  all  certificates  are  sent  after  record, 
which  central  office  must  provide  for  filing  and  preservation;  con- 
trol of  all  local  authorities  by  the  central  agency ;  penalties  provided 
and  enforced  for  all  infractions  of  the  law. 


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CHAPTER  XXIII. 
IMORBIDITY  REPORTS. 

It  is  self-evident  that  the  health  officer  cannot  take  action  upon 
any  case  of  infectious  or  communicable  disease  until  he  has  knowl- 
edge of  it.  The  law  therefore  provides  that  anyone,  and  more  par- 
ticularly any  physician,  having  knowledge  of  a  notifiable  disease 
must  report  it  to  the  health  authorities,  when  the  responsibility  of 
the  health  officer  for  quarantine  and  related  matters  at  once  begins. 
Failure  to  receive  a  formal  notification  does  not,  however,  relieve 
him  from  responsibility,  for  in  case  he  hears  of  it  in  any  other  way, 
he  must  at  once  investigate  and  take  appropriate  action,  which 
under  such  circumstances  would  probably  not  only  include  quaran- 
tine, but  prosecution  of  the  offenders. 

Blanks. — The  blanks  used  for  the  notification  of  the  health  officer 
are  usually  rather  small,  since  they  are  supposed  to  be  carried  in 
the  pocket  or  handbag  of  the  physician,  at  least  in  times  of  epi- 
demics. For  the  convenience  of  the  health  officer,  a  larger  blank 
carrying  the  necessary  data  and  with  a  sufficiently  large  margin 
to  allow  filing  on  an  arch  file  or  loose-leaf  system  would  be  prefer- 
able. It  would  allow  subsequent  separation  by  diseases  and  a  sec- 
ondary separation  alphabetically,  so  that  both  copying  and  indexing 
might  be  obviated. 

A  blank  4x8  inches,  of  which  1  inch  would  be  utilized  for  bind- 
ing, bound  in  pads  of  25,  with  a  Manila  back,  would,  if  doubled, 
take  up  not  quite  so  much  room  as  the  present  customary  3^x6  inch 
size,  and  would  give  room  for  much  important  information  not 
usually  put  down  on  the  reports. 

Physicians  should  be  required  to  use  ink  or  indelible  pencil  in 
making  out  these  reports,  as  well  as  for  those  of  a  more  permanent 
nature. 

The  headings  should  be  as  follows: 

Name  of  disease;  Name  of  patient;  Address;  Age;  Sex;  Social 
condition;  Number  in  family;  School  attended;  Schools  attended 
by  other  members  of  family;  By  whom  reported;  Time  reported 

214 


MORBIDITY   REPORTS. 


215 


(month,  day,  hour)  ;  Quarantine  instituted   (month,  day,  hour)  ; 
Disinfected  (month,  day,  hour)  ;  By  whom  disinfected. 

For  his  own  protection  the  health  officer  should  keep  this  record 
in  perfect  condition  all  the  time,  and  should  keep  the  originals,  if 
authorized  to  do  so,  or  transmit  them  promptly  to  the  proper  office 
as  the  law  may  require.  Then  he  will  be  in  position  to  show  exactly 
what  has  or  has  not  been  done  in  case  any  question  arises. 

Post  Card  Form. — At  the  1913  conference  of  the  health  authori- 
ties of  the  State  and  Federal  services,  the  following  post  card  form 
was  recommended,  which  very  readily  lends  itself  to  filing  in  a  card 
index : 

[face  of  card.] 

,   191... 

(Date.) 

Disease   or    suspected    disease 

Patient's   name ,   age ,   sex ,   color 

Patient's   address ,   occupation 

School  attended  or  place  of  employment 

Number  in  household :  Adults ,  children 

Proliahle  source  of  infection  or  origin  of  disease 

If  disease  is  smallpox,  type ,  number  of  times 

successfully  vaccinated  and  approximate  dates 

If  typhoid  fever,  scarlet  fever,  diphtheria,  or  septic  sore  throat,  was  ]mticnt, 
or  is  any  member  of  household,  engaged  in  the  production  or  handling  of 
milk    

Address  of  reporting  physician 


Signature  of  phj'sician . 


[reverse  of  CARnj 


For  use  of  local  health  depariment. 


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Gentile. 

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216  PRACTICAL   SANITATION. 

Hospital  Discharge  Certificate. — Bolduairs  siigoested  hos- 
pital discharge  certificate  is  also  of  interest  and  in  many  cities 
might  well  be  adopted : 

DI8CHARGE  CERTIFICATE. 
Xame  of  hospital Hospital  admission  No. 

How  admitted — Ambulance 
or 
own   ap])Iication 
or 
(Tabulation         transfer  from 
No.)  other  hospital. 

Patient's  address 

Borough Single  or  married  or  widowed  or  di- 

Date   admitted vorced  or  unknown. 

Date  discharged Discharged  to — 

Days   in   hospital months Plome. 

days Other  hospital. 

(If  over  a  year,   omit  the  days  and  Convalescent   retreat, 

give  only  years  and  months.)  Coroner. 

UccuiJation — (a)   Trade,  profession,  or  particular  kind  of  work. 

(b)    General  nature  of  the   industry,  business,   or   establishment 
in   which    emploj'ed    (or   employer). 

Diagnosis     

and 

Complications ■ 

If  operated  upon,  state  nature  of  operation 

Condition  on  discharge:    Cured.     Improved.     T/nimjiroved. 
Died — Autopsy. 

No  autopsy. 

Signed 

House  Physician — Svirgeon, 

Notifiable  Diseases. — The  Conference  list  of  notifiable  diseases  is 
appended.  It  will  be  noted  that  great  stress  is  very  properly  laid 
on  occupational  diseases.  An  additional  tal)h^  giving  the  reiinire- 
ments  in  the  various  states  concerning  oc;'upational  diseases  re- 
por-ls  also  follows.  For  the  tables  and  blanks  acknowledgment  is 
made  to  the  publications  of  the  Pul)lic  Health  Service,  and  par- 
ticularly to  SupphMuent  No.  ^2,  1014.  of  which  Assistant  Surgeon- 
General  Trask  is  the  author. 


MORBIDITY    REPORTS. 


217 


NOTIFIABLK    DISEASES. 


(Jroup  I. — Infections  Diseases. 

Actinomycosis. 

Anthrax. 

Cliicken-pox. 

Cholera.  Asiatic  (also  cholera  nos- 
tras when  Asiatic  cholera  is  pres- 
ent or  its  importation  threatened). 

Continued  fever  lasting  seven   days. 

Dengue. 

Diphtheria. 

Dysentery : 

(a)  Amebic. 

( b )  Bacillary. 
Favus. 

German  measles. 

Glanders. 

Hookworm  disease. 

Leprosy. 

Malaria. 

Measles. 

Meningitis: 

(a)  Epidemic    cerebrospinal. 

( b )  Tuberculous. 
Mumps. 

Ophthalmia  neonatorum  ( conjuncti- 
vitis of  new-born  infants). 

Paragonimiasis  (endemic  hemopty- 
sis) . 

Paratyphoid  fever. 

Plague. 

Pneumonia    (acute). 

Poliomyelitis    (acute  infectious). 

Rabies. 

Rocky  Mountain  spotted,  or  tick, 
fever. 

Scarlet  fever. 

Septic   sore  throat. 

Smallpox. 


Tetanus. 

Trachoma. 

Trichinosis. 

Tuberculosis   (all  forms,  the  organ  or 

part    affected    in    each    case    to    be 

specified) . 
Typhoid  fever. 
T'yphus   fever. 
Whooping  cough. 
Yellow  fever. 

Group  II. — Occupational  Diseases 
and  Injuries. 

Arsenic  poisoning. 

Brass  poisoning. 

Carbon   monoxide   poisoning. 

Lead  poisoning. 

Mercury  poisoning. 

Natural  gas  poisoning. 

Phosphorus  poisoning. 

Wood   alcohol  poisoning. 

Naphtha  poisoning. 

Bisulphide  of  carbon  poisoning. 

Dinitrobenzine  poisoning. 

Caisson  disease  (compressed-air  ill- 
ness ) . 

Anj'  other  disease  or  disability  con- 
tracted as  a  result  of  the  nature 
of  the  person's  employment. 

Group  III. — Venereal  Diseases. 
Gonococcus  infection. 
Syphilis. 

Group    IT. — Diseases    of    Unh-noicn 
Origin. 
Pellagra. 
Cancer. 


218  PRACTICAL   SANITATION. 

Occupational  Diseases  Required^  by  State  Laics  to  he  Reported. 


Poisoning  by — 

i 

s  ° 

O   to 

if 

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x' 

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X 

x' 

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x' 

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x" 

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Massachusetts  2      

Missouri     

X 
X 

New  York    

Ohio               .  .                      

x' 

1  The  Kansas  requirements  are  by  regulations  adopted  by  the  State  board  of  health  in 
December,    1913. 

2  Authority  is  given  to  the  State  board  of  labor  and  the  industrial  accident  board,  sitting 
.iointly,  to  promulgate  regulations  requiring  the  reporting  of  occupational  diseases.  These 
had  not   been  promulgated  up   to   Dec.    1,    1913. 


Occupational  Diseases. — Information  to   he   Given  in   Reports   hy   Physicians. 


Of  empl 

oyer. 

Of  pat 

lent. 

States. 

S 
X 

x 

x 
x 

X 
X 

X 
X 
X 

X 
X 

X 

to 

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T-    P. 
P4 

Duration  of 
employment 

o 

1^ 

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cs  a) 
\-,  to 

a 

121 

And     such     other     in- 
formation    as     may 
be    required   by — 

California    

Connecticut    .... 

Illinois     

Kansas     

Maryland     

Maine     

Massachusetts    .  . 

Michigan    

Minnesota    

Missouri     

New  Hampshire. 
New  Jer.sey   .... 

X 

X 
X 
X 

x' 

X 
X 

x' 

X 

X 
X 

X 
X 

X 
X 
X 
X 

X 
X 

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X 

X 
X 

X 
X 

X 
X 

X 

X 
X 

X 

X 
X 

Bureau    of    labor    sta- 
tistics. 

State  board  of  health. 
Do. 

Commissioner     of     la- 
bor. 

State  board  of  health. 
Do 

Ohio 

Pennsylvania     .  . 

Wisconsin    

X 
X 

X 

bor. 
State  board  of  health. 
State     department     of 

health. 

CHAPTER  XXIV. 
REGISTRATION  OF  DEATHS. 

Importance. — The  importance  of  a  complete  and  proper  regis- 
tration of  deaths  is  not  to  be  over-estimated  from  a  sanitary  stand- 
point. Without  it  all  statistics  are  worthless,  yet  the  registration 
area  of  the  United  States  only  covers  some  60  per  cent  of  the  popu- 
lation, comprising  the  states  (in  the  order  of  their  admission  to  the 
registration  area)  of  Massachusetts,  New  Jersey,  the  District  of 
Columbia,  Connecticut,  New  Hampshire,  Rhode  Island,  Vermont, 
Maine,  Michigan,  Indiana,  California,  Colorado,  Maryland,  Penn- 
sylvania, South  Dakota,  Washington,  Wisconsin,  Ohio,  Kentucky, 
and  Missouri,  with  isolated  cities  in  other  states.  It  is"  hoped, 
however,  on  the  basis  of  1910  reports  to  add  Delaware,  Minnesota, 
Montana,  Nebraska,  North  Dakota,  Oregon,  and  Utah,  with  munici- 
palities in  North  Carolina.  This  will  greatly  extend  the  value  of 
the  mortality  statistics,  but  still  leaves  a  notable  deficiency,  par- 
ticularly in  the  South. 

Essentials. — 1.  Immediate  registration  of  deaths,  with  issuance 
of  a  permit,  before  burial.  This  rule  must  be  absolute,  with  no 
exception  permissible.  In  coroner's  cases,  where  the  cause  of  death 
is  still  in  doubt,  the  permit  may  be  granted  on  the  coroner's  certifi- 
cate ' '  pending  investigation. ' ' 

2.  A  standard  certificate,  of  the  form  shown  on  page  220.  Since 
this  form  is  adopted  by  most  of  the  registration  states,  and  since 
only  comparable  statistics  are  of  value,  it  is  best  to  adopt  it  in  order 
that  reports  may  be  uniform. 

3.  Efficient  local  registrars,  who  are  preferably  either  health 
officers  or  someone  under  their  supervision.  No  one  else  can  have 
so  keen  an  appreciation  of  the  value  of  vital  statistics  as  the  sani- 
tarian, and  no  one  else  is  so  apt  to  take  interest  and  pride  in  their 
collection.  He  should  report  directly  to  the  state  authorities,  with- 
out any  local  officer  intervening.  This  report  should  consist  of 
the  original  death  certificates,  with  a  simple  card  of  transmittal, 
giving  the  first  and  last  numbers  of  certificates  enclosed,  with  the 

219 


220 


PRACTICAL   SANITATION. 


Standard  Certificate  of  Death. 


^i 


I     Ss 


tu.J 

5SI 


1  PLACE  OF  DEATH 


9r|iartmrnt  of  CHitmnurrr  anb  Vabar 


County  — 
Township  - 
Village  — . 
City 


STANDARD  CERTIFICATE  OF  DEATH' 

State  of — , 

Registered  No. 


«^  ,„      ..       a  hoipltal  or  Initltutlon, 

St.; Ward)      g,,,,  n,  NAME  Initnd 

ofitreet  and  number.] 


'FULL  NAME. 


PERSOIiaL  aHD  STITISTICaL  PARTICULARS 


<COLOR  OR  RACE      ' 


SDATE  OF  BIRTH 


.,   1.. 


If  LESS  than 
1  day, hrs. 


SOCCUPATION 

(a)  Trade,  profession,  or 
particular  kind  of  work 

(b)  General  nature  of  Industry, 
business,  or  establishment  in 
which  employed  (or  employer) .. 


OtIRTHPLACE 


"'■7) 


12  MAIDEN  NAME 
OF  MOTHER 


"  THE  ABOVE  13  TRUE  TO  THE  BEST  OF  MY  KNOWLEDOE 

(Informant) 

(Address) _ 


.- ,191- 


IHEDICAL  CERTirieATE  OP  DEATH 


1«  DATE  OF  DEATH 


(MoDth) 


"  I   HEREBY  CERTIFY,  That  I  attended  deceased  from 

,  191 — ,  to ..,  191...., 

that  I  last  saw  h alive  on ,  191 — , 

and  that  death  occurred,  on  the  date  stated  above,  at m. 

The  CAUSE  OF  DEATH*  was  as  follows: 


Contributory- 


.  (Duration) yri. . 


(Signed) .. 


,  191—.     (Address)  . 


:  Caui 


i  (2)  whether  i 


,  In  deaths  trooi  VtoLEHT  OAUsn,  I 
CI  DENTAL,  Sulci  UAL,  or  UOUIOIDAI,. 


IB  LENGTH    OF    RESIDENCE   (FOR 

OR  Recent  Residents) 
At  placo  In  the 

of  death yrs. mos _-ds.    State yrs. 

Where  was  disease  contracted. 

If  not  at  place  of  death  7 

Former  or 

usual  residence 


I,     iNSTTTimONa,   jRANaiENTa, 


19  PLACE  OF  BURIAL  OR  REMOVAL 


20  UNDERTAKER 


DATE  OF  BURIAL 


Standard  Certificate  of  Death  approved  by  United  States  Cen.su.s  and  American  Public 
Health  Association.  Size  of  original  form,  8  %  inches  long  by  IVi  inches  wide.  See 
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222  PRACTICAL  SANITATION, 

official  signature  of  the  registrar,  the  date  and  the  offi,cial  name  of 
his  district.  If  no  deaths  occur  iu  his  territory,  a  ' '  No  Death ' '  card 
rephices  the  report. 

4.  A  state  registrar,  who  has  full  supervision,  authority  and 
responsibility  for  the  collection  of  the  vital  statistics  of  the  state, 
and  who  is  not  afraid  to  enforce  the  penalties  of  the  law  for  neglect 
of  duty. 

5.  Responsibility  for  securing  death  certificate  and  burial  per- 
mit completely  placed  on  the  undertaker  or  other  person  disposing 
of  the  body. 

6.  For  legal  purposes,  a  local  record  which  is  an  exact  official 
copy  of  the  original  certificate.  This  is  more  fully  discussed  under 
the  head  of  Local  Records. 

7.  Eternal  vigilance  on  the  part  of  the  registrar  to  see  that  no 
bodies  are  buried  without  permits,  and  prompt  prosecution  for 
neglect  or  wilful  violation  of  the  law.  The  penalties  for  interment 
without  permits  vary  from  state  to  state.  One  of  the  most  useful 
methods  of  enforcing  the  law  is  to  place  the  expenses  of  the  Coro- 
ner's inquest,  including  autopsy,  upon  the  person  responsible  for  the 
burial,  in  addition  to  the  fine. 

The  Standard  Certificate. — The  American  Public  Health  Asso- 
ciation has  adopted  a  standard  form  of  death  certificate,  which  as 
already  stated  is  in  use  in  most  of  the  registration  states.  This 
form  was  revised  to  be  in  use  from  January  1,  1910.  The  various 
points  in  its  composition  will  be  taken  up  in  detail.  The  numbers 
refer  to  identical  numbers  on  the  certificate. 

(1)  Place  of  Death. — The  place  of  death  should  be  given  with 
particularity,  giving  county  and  city;  or  in  the  country,  giving 
township  and  county.  If  the  death  is  in  a  neighborhood  in  the 
country  known  by  a  well  identified  name,  the  neighborhood  name 
may  be  placed  in  the  space  reserved  for  street  and  number  in  cities. 
Similarly,  if  death  occurs  in  an  institution,  the  name  of  the  insti- 
tution, as  "County  Poor  Asylum"  or  "Home  for  the  Aged"  should 
be  written  in  that  space,  the  supplementary  information  being 
placed  in  space  18. 

(2)  Full  Name. — As  all  experienced  registrars  know,  the  name 
is  occasionally  a  source  of  difficulty.  If  a  body  is  unidentifiable, 
"Unknown"  should  be  written  in.  If  an  unnamed  infant,  the  name 
should  be  given  as  "Unnamed  Infant . "  Where  death  certifi- 
cates are  required  for  still-born  children,  the  same  rule  applies. 


REGISTRATION    OF    DEATHS.  223 

In  the  ease  of  illegitimate  children,  the  surname  of  the  mother  is 
used.  If,  as  sometimes  happens  among  Southern  European  immi- 
grants, a  person  is  known  among  his  own  people  by  one  name  and 
among  Americans  by  another,  both  names  are  used,  and  the  name 
indexed  in  the  local  records  by  both  titles. 

(3)  Sex. — This  is  usually  only  a  matter  of  doubt  with  monsters 
or  the  so-called  ' '  hermaphrodites. ' '  If  an  autopsy  is  not  obtainable, 
it  must  be  put  down  '^  Undetermined. " 

(4)  Color  or  Eace. — The  information  given  under  this  head  is 
frequently  not  satisfactory.  If  the  person  is  white  or  black,  without 
perceptible  admixture  of  other  blood,  it  should  be  so  stated.  If  of 
mixed  blood  and  the  parentage  can  be  ascertained  or  estimated,  the 
proportion  of  each  blood  should  be  given.  If  Chinese,  Japanese, 
East  Indian,  Malay,  Filipino,  American  Indian,  or  Polynesian,  that 
should  be  specified,  leaving  to  the  statistical  authority  the  final 
classification,  which  he  will  then  be  able  to  make  in  the  light  of  full 
information. 

(5)  Social  Condition. — This  point  is  important  not  only  to  the 
sanitarian,  but  to  the  lawyer  and  the  economist  as  well.  It  should 
never  be  omitted  when  obtainable.  Statisticians  have  been  able  to 
tabulate  quite  different  mortality  rates  for  single,  married,  widowed 
and  divorced  persons.     The  word  should  be  fully  written  in. 

(6)  Date  of  Birth. — The  date  of  birth  should  be  as  accurate 
as  possible,  and  if  birth  was  in  the  area  and  within  the  time  covered 
by  the  records  of  the  registry  office  receiving  the  death  certificate, 
it  should  be  verified.  This  is  particularly  important  in  the  case 
of  infants  of  less  than  one  year  of  age  as  it  affords  a  most  excellent 
check  on  the  effectiveness  of  the  system  of  birth  registration.  • 

(7)  Age. — The  age  must  be  exactly  stated,  and  if  less  than  one 
day,  the  hours  or  minutes  of  extra-uterine  life  are  inserted  in  the 
special  spaces.  Care  must  be  taken  that  still-births  are  not  certified 
in  a  form  which  will  allow  them  to  be  counted  as  deaths,  and  on 
the  other  hand  that  deaths  of  children  living  a  few  minutes  are  not 
returned  as  still-births. 

(8)  Occupation. — This  heading  is  usually  filled  out  very  poorly 
except  in  the  plainest  cases.  '^  Trade,  profession  or  particular  line 
of  work"  is  called  for  under  sub-head  (a)  but  is  of  no  value  in 
many  cases  unless  supplemented  by  information  contained  under 
(b)  "General  nature  of  industry,  business  or  establishment  in  which 
employed  (or  employer)."     For  example,  the  word  "laborer"  un- 


224  PRACTICAL   SANITATION. 

qualified  is  often  used.  If  the  word  "Quarry,"  ''Rolling-mill"  or 
other  line  of  industr}^  follows,  it  is  then  perfectly  easy  to  classify 
the  death  under  occupation.  As  another  example,  "Commercial 
traveler"  should  be  modified  by  "Liquor,"  "Dry  goods,"  or  other 
special  line.  "Farmer"  should  be  reserved  for  those  who  operate 
their  own  farms,  "Tenant  farmer,"  "Farm  laborer,"  etc.,  being 
used  for  others  in  agricultural  work.  Children  at  home  and  women 
engaged  in  housekeeping  for  their  own  families  alone,  are  not  occu- 
pied in  gainful  pursuits,  and  their  occupation  is  ' '  None. ' '  Children, 
no  matter  how  young,  and  women,  even  if  married,  should  have 
occupation  stated  if  employed. 

(9)  Birthplace. — For  statistical  purposes  only  the  state  or 
country  of  nativity  is  required,  but  where  it  can  be  obtained,  it  is 
better  for  legal  purposes  to  add  the  precise  place.  This  also  applies 
to  spaces  11  and  13,  giving  the  birthplaces  of  the  parents. 

(10  and  12)  Names  of  Parents. — These  are  of  importance  espe- 
cially for  legal  purposes  and  for  the  identification  of  the  record. 
"John  Smith"  is  not  a  satisfactory  index  name,  but  if  he  is  the 
son  of  Hezekiah  Smith  and  Sarepta  Brown,  the  record  is  more  satis- 
factory; if  the  father  was  born  at  Kennebunkport,  Maine,  and  the 
mother  at  Dowagiac,  Michigan,  John  Smith  at  once  is  differentiated 
from  all  the  other  Smiths  who  ever  lived. 

(14)  Witness. — The  information  on  the  left-hand  half  of  the 
certificate  should  be  obtained  from  all  sources  as  completely  as 
possible,  after  which  it  may  be  signed  by  any  member  of  the  family 
or  friend  who  is  acquainted  with  the  facts. 

(15)  Filing  Date  and  Signature. — The  date  of  filing  should 
never  be  omitted  from  the  certificate,  and  immediately  after  issuing 
the  burial  permit  the  registrar  should  note  the  fact  by  placing  his 
signature  in  the  place  provided  for  that  purpose. 

( 16 )  Date  of  Death. — This  should  always  be  given  with  scrupu- 
lous care  as  occasionally  the  disposition  of  legacies  is  altered  by  a 
difference  of  a  few  moments  in  the  death  of  husband  and  wife, 
parent  and  child  or  brother  and  sister.  The  name  of  the  month 
must  always  be  written  in  full  and  figures  are  never  to  be  used 
instead. 

(17)  Cause  of  Death. — The  cause  of  death  is  a  greater  source 
of  trouble  to  the  statistician  than  any  other  one  thing  on  the  certifi- 
cate. In  order  that  there  may  be  no  mistake  on  the  subject,  the 
International  List  of  Causes  of  Death,  with  permissible  and  unde- 


REGISTRATION    OP    DEATHS.  225 

sirable  names  has  been  appended  to  this  chapter.  It  has  the  sanc- 
tion of  the  American  Public  Health  Association,  as  well  as  of  the 
Census  Bureau,  and  should  be  closely  followed. 

Particular  care  should  be  taken  that  the  real  cause  of  death  and 
not  a  symptom,  as  shock,  hemorrhage  or  uremia  is  stated.  This 
seems  to  be  a  hard  thing  for  physicians  in  general  to  understand, 
and  the  only  remedy  is  to  insist  on  a  better  classification  by  sending 
the  report  back  for  correction,  or  in  aggravated  cases,  calling  for 
an  inquest. 

(18)  Residence  in  Hospitals,  Etc. — This  information  is  im- 
portant to  supplement  the  information  contained  in  (1),  and  should 
always  be  insisted  on,  in  the  cases  where  applicable. 

The  remaining  heads  are  self-explanatory. 

Reverse  Side. — The  reverse  side  contains  a  large  amount  of  ex- 
planatory matter,  concerning  causes  of  death,  etc. 

INTERNATIONAL  LIST  OF  CAUSES  OF  DEATH. 
[Second  Decennial  Revision,  in  effect  January  1,  1910.] 

Note. — There  is  also  a  List  of  Causes  of  Sickness,  of  precisely  identical  gen- 
eral form  but  containing  some  additional  titles,  which  should  be  used  for 
hospital  and  general  morbidity  statistics.  In  reporting  causes  of  death  upon 
certificates  of  death  the  physician  is  requested  to  read  carefully  the  instructions 
upon  the  back  of  the  certificate  (see  Standard  Certificate  of  Death)  and  enter, 
first  THE  NAME  OF  THE  DISEASE  CAUSING  DEATH;  second,  the  name  of  the 
contributory  (secondary)  cause,  if  any;  and,  third,  the  duration  of  each  cause. 
(If  death  was  influenced  by  occupation,  please  see  that  kind  of  work  and 
industry  are  correctly  stated.)  In  naming  the  disease  causing  death  it  is 
urgently  recommended  that  the  exact  names  printed  in  bold-faced  type  in 
the  List  below  be  employed,  whenever  they  are  applicable,  and  that  no 
other  terms  be  used  instead.  Thus,  always  write  Typhoid  fever;  not  some- 
times Typhoid  fever,  sometimes  Enteric  fever,  or  "  Continued  fever,"  "  Typho- 
malarial  fever,"  etc.  Of  course  many  diseases  are  not  given  in  the  terms  in 
bold-faced  type  below,  but  only  the  most  important  ones.  For  others,  any  terms 
recommended  by  the  Nomenclature  of  Diseases  of  the  Royal  College  of  Physi- 
cians, London  (fourth  edition,  1906),  or  the  Nomenclature  of  Diseases  and  Con- 
ditions of  Bellevue  and  Allied  Hospitals,  New  York  (last  edition,  1910),  may  be 
used  pending  the  publication  of  an  American  Nomenclature  of  Diseases  now  in 
hand  by  the  committee  of  the  American  Medical  Association.  Terms  printed  in 
italics  are  indefinite  or  otherwise  undesirahle,  and  should  never  he  used  when  a 
more  definite  statement  can  he  given.  "Heart  failure,"  for  example,  is  simply 
equivalent  to  cause  of  death  unknown.  "Convulsions,"  "Marasmus,"  "  De- 
hility,"  "  Old  age,"  are  terms  of  this  character.  Please  aid  in  the  improve- 
ment of  our  vital  statistics  by  using  only  precise  and  definite  terms. 


226  PRACTICAL   SANITATION. 


(I. — General  Diseases.) 

1.  Typhoid  fever. 

2.  Typhus  fever. 

3.  Relapsing  fever.     [Insert  "(spirillum)."] 

4.  Malaria. 

5.  Smallpox. 

6.  Measles. 

7.  Scarlet  fever. 

8.  Whooping  cough. 

9.  Diphtheria  and  croup. 

10.  Influenza. 

11.  Miliary  fever.     [True  Febris  miliaris  only.] 

12.  Asiatic  cholera. 

13.  Cholera  nostras. 

14.  Dysentery. 

15.  Plague. 

16.  Yellow  fever. 

17.  Leprosy. 

18.  Erysipelas.     [State  also  cause;  see  Class  XIIL] 

19.  Other  epidemic  diseases : 

Mumps, 

German  measles, 

Chickenpox. 

Rocky  Mountain  spotted  (tick)  fever, 

Glandular  fever,  etc. 

20.  Purulent     infection     and     septichsemia.     [State     also 

cause;  see  Classes  VII  and  XIII  especially.] 

21.  Glanders. 

22.  Anthrax. 

23.  Rabies. 

24.  Tetanus.     [State  also  cause;  see  Class  XIII.] 

25.  Mycoses.     [Specify,  as  Actinomycosis  of  lung,  etc.] 

26.  Pellagra. 

27.  Beriberi. 

2S.  Tuberculosis  of  the  lungs. 

29.  Acute  miliary  tuberculosis. 

30.  Tuberculous  meningitis. 

31.  Abdominal  tuberculosis. 

32.  Pott's  disease.     [Preferably  Tuberculosis  of  spine.] 

33.  White    swellings.     [Preferably    Tuberculosis    of    

joint.] 

34.  Tuberculosis  of  other  organs.     [Specify  organ.] 

35.  Disseminated  tubercxilosis.     [Specify  organs  affected.] 

36.  Rickets. 

37.  Syphilis. 

38.  Gonococcus  infection. 


REGISTRATION    OF    DEATHS.  227 

30.  Cancer  i  of  the  buccal  cavity.     [State  part.] 

40.  Cancer  i  of  the  stomach,  liver. 

41.  Cancer  i  of  the  peritonaeum,  intestines,  rectum. 

42.  Cancer  i  of  tJte  female  fjcnital  organs.     [State  organ.] 

43.  Cancer  i  of  the  breast. 

44.  Cancer  i  of  the  shin.      [State  part.] 

45.  Cancer  i  of  other  or  unspecified  organs.     [State  organ.] 

46.  Other  tumors  (tumors  of  the  female  genital  organs  ex- 

cepted.)     [Name  kind  of  tumor  and  organ  affected. 
Malignant?] 

47.  Acute  articular  rheumatism. 

48.  Chronic  rheumatism  and  gout.     [Preferably  Arthritis 

deformans.] 

49.  Scurvy. 

50.  Diabetes.     [Diabetes  mellitus.] 

51.  Exophthalmic  goitre. 

52.  Addison's  disease. 

53.  leuchsemia. 

54.  Anaemia,  chlorosis.      [State  form  or  cause.] 

55.  Other  general  diseases : 

Diabetes  insipidus. 
Purpura  hsemorrhagica,  etc. 

56.  Alcoholism  (acute  or  chronic). 

57.  Chronic  lead  poisoning.    [State  cause.    Occupational?] 

58.  Other  chronic  occupation  poisonings : 

Phosphorus  poisoning  (match  factory), 
Mercury  poisoning  (mirror  factory),  etc. 

59.  Other  chronic  poisonings: 

Chronic  morphinism, 
Chronic  cocainism,  etc. 

(II- — Diseases    of    the    JSTekvous    System    and    of    the 
Organs  of  Special  Sense.) 

60.  Encephalitis. 

61.  Meningitis : 

Cerebrospinal    fever    or    Epidemic    cerebrospinal 

meningitis, 
Simple  meningitis.  [State  cause.] 

62.  Locomotor  ataxia. 

63.  Other  diseases  of  the  spinal  cord: 

Acute  anterior  poliomyelitis. 
Paralysis  agitans, 


1  "  Cancer  and  other  malignant  tumors."      Preferably  reported  as  Carcinoma  of , 

Sarcoma  of ,  Epithelioma  of ,   etc.,  stating  the  exact  nature  of  the  neoplasm  and 

the  organ  or  part  of  the  body  first  affected. 


228  PRACTICAL   SANITATION. 

63.  Other  diseases  of  the  spinal  cord  —  Cont.: 

Chronic  spinal  muscular  atrophy, 
Primary  lateral  sclerosis  of  spinal  cord, 
Syring'omyelia,  etc. 

64.  Cerebral  haemorrhage,  apoplexy. 

65.  Softening  of  the  hrain.     [State  cause.] 

66.  Paralysis    loitliout    specified    cause.     [State    form    or 

cause.] 

67.  General  paralysis  of  the  insane. 

08.  Other  forms  of  mental  alienation.  [Name  disease 
causing  death.  Form  of  insanity  should  be  named  as 
CONTKIBUTOKY  CAUSE  Only  unless  it  is  actually  the  dis- 
ease causing  death.] 

69.  Epilepsy. 

70.  Convulsions  (nonpuerperal).     [State  cause.] 

71.  Convulsions  of  infants.     [State  cause.] 

72.  Chorea. 

73.  Neuralgia  and  neuritis.     [State  cause.] 

74.  Other  diseases  of  the  nervous  system.     [Name  the  dis- 

ease.] 

75.  Diseases  of  the  eyes  and  their  annexa.     [Name  the  dis- 

ease.] 

76.  Diseases  of  the  ears.     [Name  the  disease.] 

(III. — Diseases  of  the  Circulatory  System.) 

77.  Pericarditis.     [Acute    or    chronic;    rheumatic    (47), 

etc.] 

78.  Acute  endocarditis.     [Cause?] 

79.  Organic  diseases  of  the  heart:      [Name  the  disease.] 

Chronic  valvular  disease,  [Name  the  disease.] 

Aortic  insufficiency, 

Chronic  endocarditis, 

Fatty  degeneration  of  heart,  etc. 

80.  Angina  pectoris. 

81.  Diseases  of  the  arteries,  atheroma,  aneurysm,  etc. 

82.  Embolism  and  thrombosis.     [State  organ.     Puerperal 

(139)?] 

83.  Diseases  of  the  veins  (varices,  haemorrhoids,  phlebitis, 

etc. ) . 

84.  Diseases  of  the  lymphatic  system  (lymphangitis,  etc.) 

Cause  ?     Puerperal  ?  ] 

85.  Jlapmoirliage;  other  diseases  of  the  circulatory  system. 

[Cause?     Pulmonary  hcemorrhage  from  Tuberculosis 
of  lungs   (28)?     Puerperal?] 

(IV. — Diseases  of  the  Respiratory  System.) 

86.  Diseases  of  the  nasal  fossae.     [Name  disease.] 

67.  Diseases  of  the  larynx.    [Name  disease.    Diphtheritic?] 


REGISTRATION   OF   DEATHS.  229 

88.  Diseases  of  the  thyreoid  body.     [Name  disease.] 

89.  Acute  bronchitis. 

[Always  state  as  acute  or  chronic] 

90.  Chronic  bronchitis. 

91.  Bronchopneumonia.     [If     secondary,     give     primary 

cause.] 

92.  Pneumonia.     [If  lobar,  report  as  Lobar  pneumonia.] 

93.  Pleurisy.      [If  tuberculous,  so  report   (28).] 

94.  Pulmonary  congestion,  pulmonary  apoplexy.     [Cause?] 

95.  Gangrene  of  the  lung. 

96.  Asthma.     [Tuberculosis?] 

97.  Pulmonary  emphysema. 

98.  Other  diseases  of  the  respiratory  system   (tuberculosis 

excepted).  [Such  indefinite  returns  as  "Lung 
trouble,"  "  Pulmonary  hwrnorrhage,"  etc.,  compiled 
here,  vitiate  statistics.  Tuberculosis  of  the  lungs 
(28)  ?     Name  the  disease.] 

( V. — Diseases  of  the  Digestive  System.  ) 

99.  Diseases  of  the  mouth  and  annexa.     [Name  disease.] 

100.  Diseases   of   the   pharynx.     [Name   disease.     Diphthe- 

ritic?] 

101.  Diseases  of  the  oesophagus.     [Name  disease.] 

102.  TJlcer  of  the  stomach. 

103.  Other    diseases    of    the    stomach     (cancer    excepted). 

[Name  disease.  Avoid  such  indefinite  terms  as 
"  Stomach  troulle,"  "  Dyspepsia,"  "  Indigestion," 
"  Gastritis,"  etc.,  when  used  vaguely.] 

104.  Diarrhoea  and  enteritis    (under  2  years). 

105.  Diarrhoea  and  enteritis   (2  years  and  over). 

106.  Ankylostomiasis.     [Better,     for    the    United    States, 

Hookworm  disease  or  TTncinariasis.] 

107.  Intestinal  parasites.     [Name  species.] 

108.  Appendicitis  and  typhlitis. 

109.  Hernia,     intestinal     obstruction.     [State     form     and 

whether  strangulated.  Include  only  organic  intes- 
tinal obstruction.] 

110.  Other  diseases  of  the  intestines.     [Name  disease.] 

111.  Acute  yellow  atrophy  of  the  liver. 

112.  Hydatid  tumor  of  the  liver. 

113.  Cirrhosis  of  the  liver. 

114.  Biliary  calculi. 

115.  Other  diseases  of  the  liver.     ["Liver  complaint"  is  not 

a  satisfactory  return.] 

116.  Diseases  of  the  spleen.     [Name  disease.] 

117.  Simple  peritonitis  (nonpuerperal).     [Give  cause.] 

118.  Other   diseases   of   the   digestive   system    (cancer   and 

tuberculosis  excepted).     [Name  disease.] 


230  PRACTICAL   Sx^NITATION. 

(VI. NONVENEKEAL      DISEASES      OF      THE      GeNITOUEINAKY 

System  and  Annexa.) 

119.  Acute   nephritis.     [State   cause,   especially   if  due   to 

Scarlet  fever,  etc.] 

120.  Blight's   disease.     [Better,    Chronic   Bright's    disease, 

Chronic  interstitial  nephritis,  Chronic  parenchyma- 
tous nephritis,  etc.  Never  report  mere  names  of 
symptoms,  as  "Urcemia"  "  Urcemic  coma,"  etc.] 

121.  Chyluria. 

122.  Other  diseases  of  the  kidneys  and  annexa.     [Name  dis- 

ease.] 

123.  Calculi  of  the  urinary  passages.     [Name  bladder,  kid- 

ney.] 

124.  Diseases  of  the  bladder.     [Name  disease.] 

125.  Diseases  of  the  urethra,  urinary  abscess,  etc.     [Name 

disease.     Gonorrhoeal  (38)  ?] 

126.  Diseases  of  the  prostate.     [Name  disease.] 

127.  Nonvenereal    diseases    of    the    male    genital    organs. 

[Name  disease.] 

128.  TJterine  hsemorrhage  (nonpuerperal). 

129.  Uterine  tumor   (noncancerous).     [State  kind.] 

130.  Other  diseases  of  the  uterus.     [Name  disease.] 

131.  Cysts  and  other  tumors  of  the  ovary.     [State  kind.] 

132.  Salpingitis  and  other  diseases  of  the  female  genital  or- 

gans.     [Name  disease.     Gonorrhoeal   (38)  ?] 

133.  Nonpuerperal  diseases  of  the  breast  (cancer  excepted). 

[Name  disease.] 

(VII. — The  Puerperal  State.) 
XoTE. — The  term  puerperal  is  intended  to  include  pregnancy,  parturition,  and 
lactation.  Whenever  parturition  or  miscarriage  has  occurred  within  one  month 
before  the  death  of  the  patient,  the  fact  should  be  certified,  even  though  child- 
birth may  not  have  contributed  to  the  fatal  issue.  Whenever  a  woman  of  child- 
bearing  age,  especially  if  married,  is  reported  to  have  died  from  a  disease  which 
might  have  been  puerperal,  the  local  registrar  should  require  an  explicit  state- 
ment from  the  reporting  physician  as  to  whether  the  disease  was  or  was  not 
puerperal  in  character.     The  following  diseases  and  symptoms  are  of  this  class: 

Abscess  of  the  breast,  Metroperitonitis, 

Albuminuria,  Metrorrhagia, 

Cellulitis,  Pelviperitonitis, 

Coma,  Peritonitis, 

Convulsions,  Phlegmasia  alba  dolens, 

Eclampsia,  Phlebitis, 

Embolism,  Pyccmia, 

Gastritis,  ^eptichwmia, 
IIcBmorrhage  {uterine  or      Sudden  death, 

unqualified),  Tetanus, 

Lymphangitis,  Thrombosis. 
Metritis, 


REGISTRATION   OF   DEATHS.  231 

Physicians  are  requested  always  to  write  Puerperal  before  the  above  terms 
and  others  that  might  be  puerperal  in  character,  or  to  add  in  parentheses  (Not 
puerperal),  so  that  there  may  be  no  possibility  of  error  in  the  compilation  of 
the  mortality  statistics;  also  to  respond  courteously  to  the  requests  of  the  local 
registrars  for  additional  information  wlien,  inadvertently,  the  desired  data 
are  omitted.  The  value  of  such  statistics  can  be  greatly  improved  by  cordial 
cooperation  between  the  medical  profession  and  the  registration  officials.  If  a 
physician  will  not  write  the  true  statement  of  puerperal  character  on  the  certifi- 
cate, he  may  privately  communicate  that  fact  to  the  local  or  state  registrar,  or 
write  the  number  of  the  International  List  under  which  the  death  should  be 
compiled,  e.g.,  "  Peritonitis  (137)." 

134.  Accidents  1  of  pregnancy:      [Name  the  condition.] 

Abortion,  [Term  not  used  in  invidious  sense;  Crim- 
inal abortion  should  be  so.  specified  (184).] 
Miscarriage, 
Ectopic  gestation, 
Tubal  pregnancy,  etc. 

135.  Puerperal  haemorrhage. 

136.  Other  accidents  i  of  labor:      [Name  the  condition.] 

Caesarean  section, 

Forceps  application, 

Breech  presentation. 

Symphyseotomy, 

Difficult  labor, 

Rupture  of  uterus  in  labor,  etc. 

137.  Puerperal  septichaemia. 

138.  Puerperal  albuminuria  and  convulsions. 

139.  Puerperal  phlegmasia  alba   dolens,  embolus,  sudden 

death. 

140.  Following  childbirth    {not   otherwise  defined).     [De- 

fine.] 

141.  Puerperal  diseases  of  the  breast. 

(VIII. — Diseases  of  the  Skin  and  Cellulae  Tissue.) 

142.  Gangrene.     [State  part  affected,  Diabetic    (50),  etc.] 

143.  Furuncle. 

144.  Aciite  abscess.     [Name  part  affected,  nature,  or  cause.] 

145.  Other  diseases   of  the  skin  and  annexa.     [Name   dis- 

ease.] 

(IX. — Diseases   of   the  Bones   and   of   the   Oegans   of 
Locomotion.  ) 

146.  Diseases  of  the  bones  (tuberculosis  excepted)  :      [Name 

disease.] 


1  In   the   sense   of   conditions   or   operations  dependent  upon  pregnancy   or  labor,    not 
accidents  "   from   external   causes. 


232  PEACTICAL  SANITATION. 

Osteoperiostitis,  [Give  cause.] 

Osteomyelitis, 

Necrosis,  [Give  cause.] 

Mastoiditis,  etc.     [Following  Otitis  media  (76)   ?] 

147.  Diseases  of  the  joints    (tuberculosis  and  rheumatism 

excepted).     [Name    disease;    always    specify    Acute 
articular    rheumatism     (47),    Arthritis    deformans 

(48),   Tuberculosis  of  joint    (33),   etc.,  when 

cause  is  known.] 

148.  Amputations.     [Name     disease    or     injury    requiring 

amputation,  thus  permitting  proper  assignment  else- 
where.] 

149.  Other   diseases  of  the  organs  of  locomotion.     [Name 

disease.] 

( X. — Malformations.  ) 

150.  Cong^enital  malformations    (stillbirths  not  included)  : 

[Do  not  include  Acquired  hydrocephalus  (74)  or 
Tuberculous  hydrocephalus  (Tuberculous  menin- 
gitis)  (30)  under  this  head.] 

Congenital  hydrocephalus, 

Congenital  malformation  of  heart, 

Spina  bifida,  etc. 

(XI. — Diseases  of  Eaely  Infancy.) 

151.  Congenital    debility,    icterus,    and    sclerema:     [Give 

cause  of  debility.} 
Premature  birth. 
Atrophy,  [Give  cause.] 
Marasmus,  [Give  cause.] 
Inanition,  etc.     [Give  cause.] 

152.  Other  diseases  peculiar  to  early  infancy: 

Umbilical  haemorrhage, 

Atelectasis, 

Injury  by  forceps  at  birth,  etc. 

153.  lack  of  care. 

(XII.— Old  Age.) 

154.  Senility.     [Name  the  disease  causing  the  death  of  the 

old  person.] 

(XIII. — Affections  Produced  by  External  Causes.) 
Note. — Coroners,  medical  examiners,  and  physicians  who  certify  to  deaths 
from  violent  causes,  should  always  clearly  indicate  the  fundamental  distinction 
of  whether  the  death  was  due  to  Accident,  Suicide,  or  Homicide;  and  then  state 
the  Means  or  instrument  of  death.  The  qualification  "  probably "  may  be 
added  when  necessary. 


REGISTRATION   OF   DEATHS.  233 

155.  Suicide  by  poison.     [Name  poison.] 

156.  Suicide  by  asphjxia.     [Name  means  of  death.] 

157.  Suicide  by  hanging  or  strangulation.     [Name  means 

of  strangulation.] 

158.  Suicide  by  drowning. 

159.  Suicide  by  firearms. 

160.  Suicide  by  cutting  or  piercing  instruments.     [Name  in- 

strument.] 

161.  Suicide  by  jumping  from  high  places.     [Name  place.] 

162.  Suicide  by  crushing.      [Name  means.] 

163.  Other  suicides.     [Name  means.] 

164.  Poisoning  by  food.     [Name  kind  of  food.] 

165.  Other  acute  poisonings.     [Name  poison;  specify  Acci- 

dental.] 

166.  Conflagration.     [State  fully,  as  Jumped  from  window 

of  burning  dwelling,  Smothered  —  burning  of  the- 
ater, Forest  fire,  etc.] 

167.  Burns   (conflagration  excepted).     [Includes  Scalding,] 

168.  Absorption    of    deleterious    gases     (conflagration    ex- 

cepted) : 

Asphyxia  by  illuminating  gas  (accidental). 

Inhalation  of (accidental),  [Name  gas.] 

Asphyxia  (accidental) ,  etc.     [Name  gas.] 
Suffocation  (accidental),  etc.     [Name  gas.] 

169.  Accidental  drowning. 

170.  Traumatism  by  firearms.     [Specify  Accidental.] 

171.  Traumatism    by    cutting    or    piercing    instruments, 

[Name  instrument.     Specify  Accidental.] 

172.  Traumatism  by  fall.     [For  example.  Accidental  fall 

from  window.] 

173.  Traumatism  in  mines  and  quarries: 

Tall  of  rock  in  coal  mine. 

Injury  by  blasting,  slate  quarry,  etc. 

174.  Traumatism  by  machines.      [Specify  kind  of  machine, 

and  if  the  Occupation  is  not  fully  given  under  that 
head,  add  sufiicient  to  show  the  exact  industrial  char- 
acter of  the  fatal  injury.  Thus,  Crushed  by  pas- 
senger elevator;  Struck  by  piece  of  emery  wheel 
(knife  grinder);  Elevator  accident,  (pile  driver), 
etc.] 

175.  Traumatism  by  other  crushing: 

Railway  collision. 

Struck  by  street  car. 

Automobile  accident. 

Run  over  by  dray, 

Crushed  by  earth  in  sewer  excavation,  etc. 


234  PRACTICAL   SANITATION. 

176.  Injuries  by  animals.     [Name  animal.] 

177.  Starvation.     [Not  "  inanition  "  from  disease.] 

178.  Excessive  cold.     [Freezing.] 

179.  Excessive  heat.     [Sunstroke.] 

180.  Lightning. 

181.  Electricity      (lightning     excepted).     [How?     Occupa- 

tional?] 

182.  Homicide  by  firearms. 

183.  Homicide  by  cutting  or  piercing  instruments.     [Name 

instrument.] 

184.  Homicide  by  other  means.     [Name  means.] 

185.  Fractures    {cause  not  specified).     [State  means  of  in- 

jury. The  nature  of  the  lesion  is  necessary  for  hos- 
pital statistics  but  not  for  general  mortality  statis- 
tics.] 

186.  Other  external  causes: 

legal  hanging, 
Legal  electrocution, 

Accident,    injury,    or    traumatism     (unqualified). 
[State  Means  of  injury.] 

(XIV. — III  Defined  Diseases.) 

Note. — If  physicians  will  familiarize  themselves  with  the  nature  and  pur- 
poses of  the  International  List,  and  will  cooperate  with  the  registration 
authorities  in  giving  additional  information  so  that  returns  can  be  properly 
classified,  the  number  of  deaths  compiled  under  this  group  will  rapidly 
diminish,  and  the  statistics  will  be  more  creditable  to  the  office  that  compiles 
them  and  more  useful  to  the  medical  profession  and  for  sanitary  purposes. 

187.  Ill  defined  organic  diseases: 

Dropsy,   [Name  the  disease  of  the  heart,  liver,  or 

kidneys  in  which  the  dropsy  occurred.] 
Ascites,  etc. 

188.  Sudden  death.     [Give  cause.     Puerperal?] 

189.  Cause  of  death  not  specified  or  ill  defined.     [It  may  be 

extremely  difficult  or  impossible  to  determine  defi- 
nitely the  cause  of  death  in  some  cases,  even  if  a  post- 
mortem be  granted.  If  the  physician  is  absolutely 
unable  to  satisfy  himself  in  this  respect,  it  is  better 
for  him  to  write  Unknown  than  merely  to  guess  at 
the  cause.  It  will  be  helpful  if  he  can  specify  a  little 
further,  as  Unknown  disease  (which  excludes  ex- 
ternal causes),  or  Unknown  chronic  disease  (which 
excludes  the  acute  infective  diseases),  etc.  Even  the 
ill  defined  causes  included  under  this  head  are  at 
least  useful  to  a  limited  degree,  and  are  preferable  to 
no  attempt  at  statement.  Some  of  the  old  "  chron- 
ics," which  well-informed  physicians  are  coming  less 


REGISTRATION  OP  DEATHS. 


235 


and  less  to  use,  are  the  following:  Asphyxia;  As- 
thenia; Bilious  fever;  Cachexia;  Catarrhal  fever; 
Collapse;  Coma;  Congestion ;  Cyanosis;  DeMUty;  De- 
lirium; Dentition;  Dyspnoea;  Exhaustion;  Fever; 
Gastric  fever;  HEART  FAILURE;  Laparotomy; 
Marasmus ;  Paralysis  of  the  heart;  Surgical  shock; 
and  Teething.  In  many  cases  so  reported  the  phy- 
sician could  state  the  disease  (not  mere  symptom  or 
condition)  causing  death.] 


LIST  OF  UNDESIRABLE  TERMS. 

As  a  result  of  the  conferences  between  the  Committee  on  Nomenclature  and 
Classification  of  Diseases  appointed  by  the  American  Medical  Association  with 
committees  of  other  national  medical  organizations  and  with  medical  represent- 
atives of  the  Army,  Xavy,  Public  Health  and  Marine-Hospital  Service,  and  the 
Bureau  of  the  Census  i  it  was  agreed : 

"  That  practical  suggestions  be  framed  relative  to  the  reporting  of  causes 
of  death  and  of  sickness  by  physicians,  and  that  a  list  of  the  most  undesirable 
terms  frequently  employed  be  brought  to  their  attention  with  the  recommenda- 
tion that  they  be  disused." 

In  framing  the  following  list  of  undesirable  terms  use  has  been  made  of 
the  London  Nomenclature,  the  Bellevue  Nomenclature,  and  especially  of  the 
'•  Suggestions  to  Medical  Practitioners  respecting  Certificates  of  Causes  of 
Death,"  issued  by  the  Registrar-General  of  England  and  Wales,  and  which 
constitutes  a  part  of  the  book  of  "  Forms  for  Medical  Certificates  of  the  Cause 
of  Death  "  employed  in  that  country. 


Undesirable  Teems 

(It  is  understood  that 

the 

Reason    Why    Undesirable,    and 

term  criticised  is  in 

the 

Suggestion  for  More  Definite 

exact   form   given   below. 

Statement  of  Cause  of  Death. 

without  further  explana- 

tion or  qualification.) 

"  Alscess  " 

May    be    tuberculous,    gonorrlioeal, 

from  appendicitis,  etc.,  or  relate 
to  any  part  of  the  body.     The  re- 
turn   is    worthless.     State    cause 
(in  which  case  the  fact  of  "ab- 
scess "  may  be  quite  unimportant) 
and  location. 

"  Accident,"  "  Injury,"  " 

Ex- 

Impossible  to  classify  satisfactorily. 

ternal      causes,"      " 

Vio- 

Always  state   (1)   whether  Acci- 

lence."    Also  more  specific 

dental,   Suicidal,   or   Homicidal; 

1  Mortality  Statistics,   1907,  p.   19. 


236 


PEACTICAL  SANITATION. 


Undesirable  Teems. 


terms,  as  "  Drowning," 
"  Gunshot,"  which  might 
be  either  accidental,  sui- 
cidal, or  homicidal. 


Atrophy,"  "  DeliUty," 

"  Decline,"  "  Exhaustion," 
"  Inanition,"  "  Weakness," 
and  other  vague  terms. 


"  Cancer," 
"  Sarcoma,' 


'  Carcinoma," 
etc. 


Congestion,"  "  Congestion 
of  bowels,"  '•'  Congestion  of 
brain,"  "  Congestion  of 
kidneys,"  "  Congestion  of 
lungs,"  etc. 


Convulsions  " 


"  Croup  " 


Reason  Why  Undesirable,  and 
Suggestion  foe  More  Definite 
Statement  of  Cause  of  Death. 


and  (2)  Means  of  injury  (e.g., 
Eailroad  accident).  The  lesion 
(e.g.,  Fracture  of  skull)  may  be 
added,  but  is  of  secondary  im- 
portance for  general  mortality 
statistics. 

Frequently  cover  tuberculosis  and 
other  definite  causes.  Name  the 
disease  causing  the  condition. 

In  all  cases  the  organ  or  part  first 
affected  by  cancer  should  be  speci- 
fied. 

Alone,  the  word  "  congestion "  is 
worthless,  and  in  combination  it 
is  almost  equally  undesirable.  If 
the  disease  amounted  to  inflamma- 
tion, use  the  proper  term  (pneu- 
monia, nephritis,  enteritis,  etc.)  ; 
merely  passive  congestion  should 
not  be  reported  as  a  cause  of  death 
when  the  primary  disease  can  be 
ascertained. 

"  It  is  hoped  that  this  indefinite 
term  will  henceforth  be  restricted 
to  those  cases  in  which  the  true 
cause  of  that  symptom  can  not 
be  ascertained.  At  present  more 
than  eleven  per  cent  of  the  total 
deaths  of  infants  under  one  year 
old  are  referred  to  '  convulsions ' 
merely." —  Registrar-General.  The 
Chicago  Health  Department  re- 
fuses to  accept  this  statement,  and 
has  entirely  eliminated  this  indefi- 
nite return. 

"  Croup  "  is  a  most  pernicious  term 
from  a  public  health  point  of  view, 
is  not  contained  in  any  form  in 
the  London  or  Bellevue  Nomencla- 


REGISTRATION  OF  DEATHS. 


237 


Undesirable  Teems. 


Reason  Why  Undesibable,  and 
Suggestion  for  More  Definite 
Statement  of  Cause  of  Death. 


'  Dropsy  •' 


"  Fracture"    "  Fracture    of 
skull,"  etc. 


"  Gastritis,"  "  Acute 
tion" 


Heart     disease" 
trouble,"    even    ' 
heart  trouble." 


"  Heart 
Organic 


"Heart  failure,"  "  Cardiac 
weakness"  "  Cardiac  as- 
thenia," "  Paralysis  of  the 
heart,"  etc. 


tures,  and  should  be  entirely  dis- 
used. Write  Diphtheria  when 
this  disease  is  the  cause  of  death. 

"  Dropsy  "  should  never  be  returned 
as  the  cause  of  death  without 
particulars  as  to  its  probable 
origin,  e.  g.,  in  disease  of  the 
heart,  liver,  kidneys,  etc." — Reg- 
istrar-General. Name  the  disease 
causing  (the  dropsy  and)  death. 

Indefinite;  the  principle  of  classifi- 
cation for  general  mortality  sta- 
tistics is  not  the  lesion  but  (1) 
the  nature  of  the  violence  that 
produced  it  (Accidental,  Suicidal, 
Homicidal),  and  (2)  the  Means 
of  injury. 

Frequently  worthless  as  a  statement 
of  the  actual  cause  of  death;  the 
terms  should  not  be  loosely  used 
to  cover  almost  any  fatal  affec- 
tion with  irritation  of  stomach. 

Some  cavil  at  the  probable  correct- 
ness of  such  returns,  and  it  is 
better  to  state  clearly  the  exact 
form  of  the  cardiac  affection,  as 
Mitral  regurgitation.  Aortic 
stenosis,  or  even  as  Valvular 
heart  disease,  rather  than  to  use 
the  less  precise  language. 

"  Heart  failure "  is  a  recognized 
synonym,  even  among  the  laity, 
for  ignorance  of  the  cause  of  death 
on  the  part  of  the  physician. 
Such  a  return  is  forbidden  by  law 
in  Connecticut;  if  the  physician 
can  make  no  more  definite  state- 
ment, it  must  be  compiled  among 
the  class  of  ill  defined  diseases 
(not  under  Organic  heart  dis- 
ease ) . 


238 


PRACTICAL   SANITATION. 


Undesirable  Teems. 


Reason  Why  Undesirable,  and 
Suggestion  for  More  Definite 
Statement  of  Cause  of  Death. 


"  HcBino7'rhage" 
optysis." 


"  Hcem- 


"  Hydrocephalus  " 


Hysterectomy  "   . . . . 
'  Infantile  paralysis  " 


Inflammation  " 


"  Laparotomy  " 


Malignant,"      "  Malignant 
disease." 


Frequently  mask  tuberculosis  or 
deaths  from  injuries  (traumatic 
haemorrhage),  Puerperal  haemor- 
rhage, or  haemorrhage  after  opera- 
tion for  various  conditions.  Name 
the  disease  causing'  death  in  the 
course  of  which  the  "  Haemor- 
rhage "  was  an  incident. 

"  It  is  desirable  that  deaths  from 
hydrocephalus  of  tuberculous 
origin  should  be  definitely  as- 
signed in  the  certificate  to  Tuber- 
culous meningitis,  so  as  to  dis- 
tinguish them  from  deaths  caused 
by  simple  inflammation  or  other 
disease  of  the  brain  or  its  mem- 
branes. Congenital  hydrocepha- 
lus should  always  be  returned  as 
such." — Registrar-General. 

See  Operation. 

This  term  is  sometimes  used  for  pa- 
ralysis of  infants  caused  by  in- 
strumental delivery,  etc.  The  im- 
portance of  the  disease  in  its 
present  endemic  and  epidemic 
prevalence  in  the  United  States 
makes  the  exact  and  unmistak- 
able expressions  Acute  anterior 
poliomyelitis  or  Infantile  pa- 
ralysis (acute  anterior  polio- 
myelitis) desirable. 

Of  what  organ  or  part  of  the  body? 

Cause? 

See  Operation. 

Should  be  restricted  to  use  as  qual- 
ification for  neoplasms;  see  Tu- 
mor. 


REGISTRATION   OF   DEATHS. 


239 


Undesirable  Teems. 


Reason  Why  Undesibable,  and 
Suggestion  fob  More  Definite 
Statement  of  Cause  of  Death. 


Marasmus  " 


Meningitis,"  "  Cerebral 
meningitis"  "  Cerebro- 
spinal meningitis,"  "Spi- 
nal meningitis." 


Natural  causes" 


Operation"  "  Surgical  op- 
eratio  n,"        "  Surgical 


This  term  covers  a  multitude  of 
worthless  returns,  many  of  which 
could  be  made  definite  and  useful 
by  giving  the  name  of  the  disease 
causing  the  "  marasmus  "  or  wa- 
sting. It  has  been  dropped  from 
the  English  Nomenclature  since 
1885  ("Marasmus,  term  no  longer 
used  " ) .  The  Bellevue  Hospital 
Nomenclature  also  omits  this 
term. 

Only  two  terms  should  ever  be  used 
to  report  deaths  from  06161)10- 
spinal  fever,  synonym,  Epidemic 
cerebrospinal  meningitis,  and 
they  should  be  written  as  above 
and  in  no  other  way.  It  matters 
not  in  the  use  of  the  latter  term 
whether  the  disease  be  actually 
epidemic  or  not  in  the  locality. 
A  single  sporadic  case  should  be  so 
reported.  The  first  term  (Cerebro- 
spinal fever)  is  preferable  because 
there  is  no  apparent  objection 
to  its  use  for  any  number  of  cases. 
No  one  can  intelligently  classify 
such  returns  as  are  given  in  the 
margin.  Mere  terminal  or  symp- 
tomatic meningitis  should  not  be 
entered  at  all  as  a  cause  of  death; 
name  the  disease  in  which  it  oc- 
curred. Tuberculous  meningitis 
should  be  reported  as  such. 

Coroners  and  justices  of  the  peace 
may  often  be  able  to  make  a 
more  definite  return,  although 
even  this  has  value  as  elimina- 
ting external  causes.  What  dis- 
ease caused  death? 

All  these  are  entirely  indefinite  and 
unsatisfactory  —  unless    the    sur- 


240 


PRACTICAIi   SANITATION. 


Reason    Why    Undesirable,    and 

Undesirable  Terms. 

Suggestion  foe  More  Definite 

Statement  of  Cause  of  Death. 

shock,     "  Amputation," 

oeon  desires  his  work  to  be  lield 

"  Hysterectomy,"    . "  Lap- 

primarily    responsible     for     the 

arotomy,"  etc. 

death;  in  which  case,  as  in  some 

certificates  actually  returned,  he 

may   facilitate   understanding  by 

signing  his  name  as  the  cause  of 

death !     Name  the  disease  or  form 

of    external    violence    (Means    of 

death;     accidental,    suicidal,    or 

homicidal?). 

"  Paralysis,"    "  General   pa- 

The vague  use  of  these  terms  should 

ralysis,"  "  Paresis,"  "  Gen- 

be avoided,  and  the  precise  form 

eral     paresis,"     "  Palsy," 

stated,   as  Acute   ascending   pa- 

etc. 

ralysis,  Paralysis  agitans.  Bulbar 

paralysis,  etc.     Write  General  pa- 

ralysis of  the  insane  in  full,  not 

omitting  any  part  of  the  name; 

this  is  essential  for  satisfactory 

compilation  of  this  cause.     Distin- 

guish    Paraplegia     and     Hemi- 

plegia; and  in  the  latter,  v^hen  a 

sequel   of   Apoplexy   or   Cerebral 

haemorrhage,  report  the  primary 

cause. 

"  Peritonitis  " 

"  Whenever  this  condition  occurs  — 

either  as  a  consequence  of  Hernia, 

Perforating  ulcer  of  the  stomach 

or  bowel   [Typhoid  fever?],  Ap- 

pendicitis, or  Metritis  (puerperal 

or  otherwise ) ,  or  else  as  an  exten- 

sion   of    morbid    processes    from 

other  organs  [Name  the  disease], 

the  fact  should  be  mentioned  in 

the     certificate." — Registrar-Gen- 

eral.    Always    specify    Puerperal 

peritonitis  in  cases  resulting  from 

abortion,  miscarriage,  or  labor  at 

full   term.     When   traumatic,   re- 

port means  of  injury  and  whether 

accidental,  suicidal,  or  homicidal. 

REGISTRATION  OF  DEATHS. 


241 


Undesirable  Terms. 


Reason  Why  Undesirable,  and 
Suggestion  for  More  Definite 
Statement  of  Cause  of  Death. 


Pneumonia,' 
pneumonia.' 


Typhoid 


Ptomaine  poisoning,"  "  Au- 
tointoxication," "  Tox- 
aemia," etc. 


"  Pneumonia,"  without  qualification, 
is  indefinite;  it  should  be  clearly 
stated  either  as  Bronchopneu- 
monia or  Lobar  pneumonia.  The 
terms  Croupous  pneumonia  and 
Lobular  pneumonia  are  also  clear, 
and  the  London  Nomenclature  pro- 
vides for  the  variety  Epidemic 
pneumonia.  "  The  term '  Typhoid 
pneumonia '  should  never  be  em- 
ployed, as  it  may  mean  either  En- 
teric fever  [Typhoid  fever]  with 
pulmonary  complications,  on  the 
one  hand,  or  Pneumonia  with  so- 
called  typhoid  symptoms  on  the 
other." — Registrar-General.  When 
occurring  in  the  course  of  or  fol- 
lowing a  disease,  the  primary 
cause  should  be  reported,  as 
Pneumonic  typhoid.  Plague 
(pneumonic  form).  Measles  fol- 
lowed by  bronchopneumonia.  In- 
fluenza (pneumonia),  etc.  Do 
not  report  "Hypostatic  pneu- 
monia "  or  other  mere  terminal 
conditions  as  causes  of  death  when 
the  disease  causing  death  can  be 
ascertained. 

These  terms  are  used  very  loosely 
and  it  is  impossible  to  compile 
statistics  of  value  unless  greater 
precision  can  be  obtained.  "  Pto- 
maine poisoning "  should  be  re- 
stricted to  deaths  resulting  from 
the  development  of  putrefactive 
alkaloids  or  other  poisons  in  food, 
and  the  food  should  be  named,  as 
Ptomaine  poisoning  (mussels), 
etc.  Such  terms  should  not  be 
used  when  merely  descriptive  of 
symptoms  or  conditions  arising  in 
the    course    of   diseases,   but   the 


242 


PRACTICAL   SANITATION. 


Reason    Why    Undesirable,    and 

Undesirable  Terms. 

Suggestion  for  Mobe  Definite 

Statement  of  Cause  of  Death. 

disease     causing     death     should 

alone  be  named. 

"  Tabes    mesenteric  a," 

"  The    use    of    this    term    ["  Tabes 

"  Tabes." 

mesenterica"]  to  describe  tubercu- 

lous disease  of  the  peritonaeum  or 

intestines  should  be  discontinued, 

as  it  is  frequently  used  to  denote 

various    other    wasting    diseases 

which       are      not      tuberculous. 

Tuberculous    peritonitis    is    the 

better  term  to  employ  when  the 

condition   is   due   to  tubercle." — 

Registrar-General.    Tabes  dorsalis 

should     not     be     abbreviated    to 

"  Tabes." 

"  Tuberculosis  "    

The  organ  or  part  of  the  body  af- 
fected   should    always   be    stated, 

as    Tuberculosis    of    the    lungs, 

Tuberculosis      of      the      spine, 

Tuberculous    meningitis,    Acute 

general      miliary      tuberculosis. 

etc. 

"  T  u  m  0  r,"      "  Neoplasm," 

These  terms   should  never  be  used 

"  New  growth." 

without     the     qualifying     words 

Malignant,     Nonmalignant,     or 

Benign.     If  malignant,   they  be- 

long   under    Cancer,    and    should 

preferably  be  so  reported,  or  un- 

der  the   more   exact   terms  .  Car- 

cinoma,    Sarcoma,    etc.    In    all 

cases  the  organ  or  part  affected 

should  be  specified. 

"  Vrcemia  "    

Name  the  disease  causing  death. 

CHAPTER  XXV. 
THE  DISPOSAL   OF  THE  DEAD. 

Among  all  races  of  men  and  in  all  times,  there  have  been  special 
ceremonials  connected  with  the  disposal  of  the  dead,  and  certain 
methods  of  disposal  have  been  favored  and  others  abhorred.  They 
have  been  swathed  in  furs  and  blankets  and  placed  on  scaffolds 
as  among  our  western  Indians ;  exposed  to  have  the  flesh  picked 
from  the  bones  by  vultures  as  among  the  Parsees  of  India ;  mummi- 
fied with  salt,  saltpetre,  spices  and  bitumen  as  in  Egypt  and  Peru ; 
burned  on  funeral  pyres  as  in  ancient  Greece  and  modern  India; 
buried  in  the  earth  permanently  or  temporarily  until  decompo- 
sition has  removed  the  flesh ;  placed  in  vaults,  rock  tombs  or  mau- 
soleums ;  deposited  in  the  sea ;  covered  with  cairns ;  and  most  to 
the  satisfaction  of  the  sanitarian,  in  the  most  civilized  nations,  are 
with  increasing  frequency  cremated  in  the  rosy  glow  of  the  modern 
crematorium. 

Almost  all  of  these  methods  have  one  thing  in  common — a  desire 
to  remove  the  dead  from  the  vicinity  of  the  living  because  of  a 
supposed  malign  influence  which  they  might  exert.  Among  un- 
civilized or  superstitious  communities,  this  malignant  influence  is 
attributed  to  ghosts;  among  enlightened  peoples,  to  disease.  How 
much  there  may  be  in  this  idea  will  be  discussed  in  a  later  para- 
graph of  this  chapter. 

As  stated  in  the  preceding  chapter,  a  preliminary  to  any  inter- 
ment should  be  the  presentation  of  a  properly  fiUed-out  death 
certificate,  and  the  giving  of  a  formal  permit  by  the  accountable 
health  officer  or  deputy.  By  this  means  the  community  assures 
itself  that  foul  play  has  not  been  done,  and  in  the  case  of  infectious 
diseases  of  dangerous  type,  prevents  a  public  funeral  which  would 
help  to  scatter  the  contagion. 

In  the  United  States,  practically  only  three  of  the  above  men- 
tioned methods  of  disposing  of  the  dead  are  in  use — burial  in  the 
ground,  deposit  in  vaults,  and  cremation.  Properly  done,  there 
is  no  sanitary  objection  to  any  of  them.     Cemeteries  should  not  be 

243 


244  PRACTICAL   SANITATION. 

located  where  their  drainage  can  contaminate  a  water  supply,  but 
aside  from  this,  they  may  be  located,  in  the  absence  of  legal  prohi- 
bition, anywhere.  Vaults  are  at  present  only  used  for  the  tem- 
porary or  permanent  reception  of  embalmed  bodies,  enclosed  in 
hermetically  sealed  caskets.  The  modern  crematory  furnace  has 
about  it  nothing  to  offend  any  of  the  senses,  the  body  being  reduced 
to  its  constituent  gases  and  a  mere  handful  of  ash  within  an  hour 
or  two.  If  there  be  any  choice  among  these  methods,  it  falls  on 
the  third  for  aesthetic  and  utilitarian  reasons  rather  than  for  sani- 
tary considerations.  Eapid  resolution  of  the  body  into  its  elements 
by  fire  is  a  much  pleasanter  thing  to  contemplate  than  slow  destruc- 
tion by  the  ordinary  processes  of  decomposition,  as  all  who  have 
had  to  disinter  bodies  will  agree ;  furthermore,  cemeteries  withdraw 
from  cultivation  land  which  becomes  increasingly  more  needed  with 
augmenting  population. 

Many  .states  require  a  license  for  undertakers  and  embalmers, 
basing  the  right  to  license  upon  examination.  This  examination 
usually  covers  a  rough  knowledge  of  anatomy,  the  processes  of  em- 
balming, something  of  infectious  diseases,  methods  of  disinfection 
of  corpses  and  their  preparation  for  burial  or  removal,  and  the 
legal  phases  of  their  work,  besides  strictly  professional  questions. 
This  licensing  of  undertakers  is  a  matter  of  importance,  since  it 
secures  intelligent  men  for  duties  which  are  necessary  for  the  public 
welfare.  For  this  reason  also,  undertakers  are  frequently  chosen 
as  deputy  health  officers. 

Dead  bodies,  before  they  can  be  received  for  shipment  by  rail, 
boat  or  express,  must  be  furnished  with  a  transportation  permit, 
which  is  in  the  case  of  non-infectious  diseases,  on  white  paper,  and 
of  infectious  diseases  on  colored  paper.  This  transportation  per- 
mit contains  all  the  data  on  the  burial  permit,  and  is  first  signed 
by  the  attending  physician  or  coroner,  permission  to  remove  the 
body  is  given  by  the  health  officer  in  the  next-following  section,  and 
the  undertaker  certifies  in  the  last  section  that  the  law  relating  to 
shipment  of  corpses  has  been  fully  complied  with.  The  transpor- 
tation is  in  duplicate,  one  half  being  carried  by  the  person  author- 
ized to  accompany  the  body  or  the  express  messenger,  if  shipment 
is  by  express,  and  the  duplicate  being  forwarded  by  the  carrying 
company  to  the  State  Board  of  Health.  Railroads  and  express  com- 
panies are  required  to  make  monthly  reports  to  State  Boards  of 
Health,  which  places  a  check  on  the  issuance  of  permits  of  this  class 


THE  DISPOSAL  OF   THE  DEAD.  245 

without  a  full  compliance  with  the  law.  Indiana  and  some  other 
states  require  a  burial  permit  to  accompany  the  transit  permit,  but 
in  the  ease  of  bodies  shipped  in  from  other  states  allow  the  burial 
permit  to  be  made  out  from  the  transportation  papers,  in  the  ab- 
sence of  a  permit  made  out  at  the  place  of  origin. 

The  rules  of  most  State  Boards  of  Health  and  the  statutes  of  most 
states  contain  an  absolute  prohibition  of  the  transportation  of 
bodies  dead  of  smallpox,  Asiatic  cholera,  bubonic  plague,  typhus 
and  yellow  fever.  In  the  case  of  at  least  two  of  these  diseases,  the 
prohibition  is  entirely  unnecessary.  Yellow  fever  is  never,  accord- 
ing to  our  present  views  of  its  etiology,  contracted  in  any  way 
except  by  the  bite  of  a  special  mosquito,  and  Asiatic  cholera  is  no 
more  dangerous  than  typhoid  fever,  which  is  permitted  to  be  trans- 
ported. It  is  hard  to  see  how  either  of  the  other  three  diseases 
can  be  disseminated  through  the  medium  of  a  dead  body  prepared 
as  described  in  the  next  paragraph. 

"The  bodies  of  those  who  have  died  of  diphtheria  (membranous 
croup),  scarlet  fever  (scarlatina,  scarlet  rash),  glanders,  anthrax 
or  leprosy,  shall  not  be  accepted  for  transportation  unless  prepared 
for  shipment  by  being  thoroughly  disinfected  by  (a)  arterial  and 
cavity  infection  with  an  approved  disinfecting  fluid,  (b)  disinfect- 
ing and  stopping  of  all  orifices  with  absorbent  cotton,  and  (c) 
washing  the  body  with  the  disinfectant,  all  of  which  must  be  done 
by  an  embalmer  holding  a  certificate  from  the  State  Board  of 
Embalmers.  After  being  disinfected  as  above,  such  body  shall  be 
enveloped  in  a  layer  of  cotton  not  less  than  one  inch  thick,  com- 
pletely wrapped  in  a  sheet  and  bandaged  and  encased  in  an  air-tight 
zinc,  tin,  copper,  or  lead-lined  coffin  or  iron  casket,  all  joints  and 
seams  hermetically  soldered,  and  all  enclosed  in  a  strong,  tight 
wooden  box."  {Rules  of  the  Indiana  State  Board  of  Health.)  As 
an  alternative,  the  body  disinfected  and  prepared  as  above  may  be 
placed  in  a  coffin  or  casket,  and  this  enclosed  in  the  metallic  case, 
which  is  afterwards  soldered  shut. 

In  the  case  of  those  dead  of  typhoid  fever,  puerperal  fever,  ery- 
sipelas, tuberculosis  and  measles,  the  rules  are  relaxed  to 
allow  transportation  after  preparation  by  cavity  injection  only, 
the  washing,  wrapping,  and  stopping  of  orifices  being  done  as 
in  the  preceding  paragraph,  and  the  air-tight  casket  being  also  re- 
quired. 

Those  dead  of  non-infectious  diseases  may  be  shipped  in  the 


246  PRACTICAL   SANITATION. 

ordinary  casket  and  rough-box,  if  properly  embalmed  by  a  licensed 
embalmer. 

Since  all  of  the  modern  embalming  fluids  contain  such  powerful 
antiseptics  as  formaldehyd,  zinc  chloride,  mercuric  chloride  and 
alcohol,  it  is  difficult  to  see  why  any  germs  of  disease  are  not 
promptly  destroyed,  and  in  fact  there  is  no  reason  to  think  they 
are  not.  There  is  but  little  reason  also  why  any  contagion  should 
linger  for  more  than  a  very  few  days  around  any  corpse,  since  the 
bacteria  of  putrefaction  will  overgrow  and  destroy  almost  any  of 
the  pathogenic  organisms  except  tetanus  and  anthrax. 

Arsenical  embalming  fluids  are  almost  everywhere  forbidden, 
as  making  it  possible  to  cover  up  arsenical  poisoning  when  that 
drug  has  been  given  with  homicidal  intent. 


CHAPTER  XXVI. 
SCHOOL  INSPECTION. 

Importance. — ^When  it  is  considered  that  from  5  to  7  hours  of  5 
days  in  the  week  for  from  5  to  10  months  in  the  year  are  obligatory 
in  most  states  for  every  child  between  the  ages  of  6  and  14,  the 
importance  of  a  careful  sanitary  oversight  of  the  schools  becomes 
at  once  apparent.  Modern  civilization  demands  universal  educa- 
tion, but  this  will  rapidly  become  universal  deterioration  unless 
the  waste  of  the  health  of  the  future  fathers  and  mothers  of  the 
race,  due  to  bad  air,  bad  lighting,  bad  seating,  overcrowding  and 
the  mingling  of  sick  with  well  children  are  prevented. 

These  duties  are  sometimes  undertaken  by  the  health  officer  and 
sometimes  by  special  medical  inspectors  of  schools.  Whoever  is 
charged  with  these  duties  by  law  should  be  continually  alive  to  his 
responsibilities  and  always  on  the  alert  to  correct  defects  either 
in  his  charges  or  their  environment.  In  childhood  many  conditions 
may  be  remedied  or  prevented  that  in  adult  life  may  gravely  com- 
promise the  health  or  usefulness  of  the  individual. 

Buildings. — Site. — The  site  of  a  school  building  must  be  well- 
drained,  either  by  nature  or  artificially;  it  must  be  convenient  of 
access;  it  should  not  be  near  enough  to  railroads  or  noisy  factories 
to  allow  the  noise  to  interfere  with  work;  it  should  have  ample 
playground  space;  it  should  have  some  shade;  the  surface  should 
be  gravelled  or  turfed;  walks  must  connect  the  schoolhouse  with 
the  street  or  road  and  with  outhouses  and  water  supply. 

Foundation. — The  foundation  must  be  impervious  to  soil-water 
in  order  that  capillarity  may  not  dampen  the  walls.  They  should 
be  of  non-porous  natural  stone,  hard-burned  brick  or  concrete,  and 
if  of  concrete,  must  have  a  layer  of  tarred  felt,  tarred  paper  or 
impervious  stone  or  brick  interposed  between  the  foundation  and 
the  superstructure. 

Basement. — If  there  is  a  basement,  it  should  rise  sufficiently  high 
above  the  ground  for  light  and  air  to  penetrate  to  every  part  of  it, 
and  should  never  be  allowed  to  become  a  dump  for  refuse  of  any 

247 


248  PRACTICAL   SANITATION. 

kind.  If  no  basement  is  provided,  the  foundation  walls  should  be 
pierced  in  appropriate  places  and  guarded  with  gratings,  in  order 
to  allow  a  circulation  of  air  below  the  floors. 

Cloak-rooms. — These  must  always  be  provided  in  order  to  avoid 
the  stuffy  and  disagreeable  odor  of  clothing  in  damp  weather.  In 
the  country,  shelves  for  dinner  pails  should  also  be  provided. 
•  Toilets. — These  must  be  separate  for  the  sexes,  well  screened, 
well  painted  or  whitewashed,  and  kept  clean.  If  water-closets  are 
used,  a  type  should  be  selected  which  can  easily  be  scrubbed,  and 
an  automatic  flush  is  desirable.  Outdoor  privies  should  take  the 
type  of  those  recommended  in  Chapter  XXXII.  Urinals  must  be 
placed  in  the  toilets  allotted  to  boys. 

Wash  Booms. — It  is  patent  that  children  should  be  afforded  an 
opportunity  and  taught  to  use  it,  for  cleansing  the  hands  and  face 
after  play  or  visits  to  the  toilet.  For  this,  if  piped  water  is  avail- 
able, the  ordinary  porcelain  basins  with  run-off  to  the  sewer  con- 
nection should  be  installed.  In  case  it  is  not  available,  ordinary 
granite  or  enamelled  basins,  with  a  water  supply  in  buckets  or 
tanks  should  be  possible  to  any  school.  Paper  towels  or  individual 
towels  brought  by  the  children  must  be  used.  The  use  of  roller 
towels  is  an  abomination. 

Water  Supply. — This  is  to  be  inspected  according  to  the  rules 
laid  down  in  Chapter  XXXVII.  In  many  localities,  the  use  of  a 
windmill  or  gasoline  engine  will  make  possible  a  supply  of  water 
under  pressure,  using  either  an  elevated  tank  or  air-pressure  base- 
ment tank  for  storage.  This  will  provide  not  only  water  for  drink- 
ing and  washing,  but  for  water-closets,  the  outflow  from  which  can 
be  purified  by  a  septic  tank  before  its  final  disposal. 

Schoolrooms. — Space. — Not  less  than  225  cubic  feet  of  space 
must  be  allotted  to  each  person  in  the  schoolroom,  including  the 
teacher.  Rooms  not  affording  this  amount  of  space  are  over- 
crowded and  transfers  must  be  compelled  until  the  condition  is 
relieved.     12-foot  ceilings  are  best  for  all  purposes. 

Ventilation. — ^Whatever  means  are  used  must  provide  for  a  com- 
plete change  of  air  in  15  to  20  minutes.  This  is  best  tested  by  using 
a  "bee-smoker"  which  fills  the  air  with  light  smoke  from  burning 
rags,  and  if  the  air  is  completely  clear  in  the  time  named,  the  venti- 
Intion  may  be  regarded  as  satisfactory. 

Three  principal  systems  of  ventilation  are  in  use:  the  indirect, 
which  utilizes  differences  of  temperature  between  inside  and  out- 


SCHOOL  INSPECTION.  249 

side  air  to  cause  au  exchange  between  themj  the  exhaust,  which 
draws  out  the  air  from  the  room,  and  the  plenum,  which  forces  air 
under  pressure  into  it.  The  first  system  is  the  one  in  common  use. 
The  heat  of  a  chimney,  of  hot  air  ducts,  fireplaces  or  stoves,  or 
appropriately  placed  steam-coils,  heats  the  air  in  an  outflow  duct 
which  rises  and  fresh  air  is  drawn  in  through  another  duct  to  re- 
place it.  This  system  tends  to  break  down  as  the  weather  begins 
to  get  warm,  since  there  is  not  sufficient  difference  of  temperature 
to  secure  the  required  circulation.  The  exhaust  system  supplies 
the  necessary  fresh  air,  but  not  all  of  it  comes  in  through  the  inlet 
ducts,  part  of  it  being  drawn  in  around  doors  and  windows  and 
creating  unpleasant  drafts.  The  plenum  system,  on  the  other  hand, 
supplies  more  air  than  can  be  ejected  through  the  outlets.  The 
best  method  is  found  to  be  the  use  of  two  fans,  one  of  which  forces 
in  slightly  more  air  than  the  second  or  exhaust  fan  can  remove. 
No  matter  what  system  is  used,  it  will  be  of  no  value  unless  it  will 
pass  the  smoke  or  similar  test,  and  should  be  bought  under  a  guaran- 
tee to  change  completely  the  air  in  a  room  within  15  to  20  minutes. 

Heating. — ^Whatever  system  of  heating  is  employed  should  main- 
tain the  temperature  of  every  part  of  the  schoolroom  between  65° 
and  70°  F.,  with  a  relative  humidity  of  at  least  40  per  cent.  Should 
the  temperature  fall  below  60°  the  school  must  be  dismissed  at 
once.  If  stoves  are  used,  they  must  be  surrounded  by  screens  so 
as  to  secure  a  better  circulation  of  air  and  to  protect  the  pupils 
who  sit  near.  Steam  heat  should  not  be  used  for  study  rooms  un- 
less the  air  is  heated  by  passing  over  steam  coils  in  the  inlet  duct. 
Naked  radiators  are  very  undesirable  in  the  study  room,  but  are 
permissible  for  recitation,  manual  training,  office  rooms  and  halls. 
Many  devices  for  using  the  heated  air  to  secure  ventilation  are  in 
use,  but  none  should  be  permitted  to  be  installed  or  used  which  fall 
short  of  the  requirements  stated  in  the  next  paragraph. 

Humidity. — Some  means,  even  if  only  the  placing  of  pans  of 
water  on  stoves  or  radiators,  must  be  provided  for  adding  to  the 
moisture  in  the  air.  Cold  air  is  robbed  of  its  moisture,  and  reheat- 
ing greatly  increases  its  capacity  for  absorbing  water  vapor.  Air 
that  is  too  dry  is  unpleasant  to  breathe,  and  is  necessary  to  be 
maintained  at  a  higher  temperature  for  comfort  than  moist  air. 
Hence  it  is  economy  as  well  as  good  sanitation  to  humidify  the 
atmosphere  in  some  manner. 

Light. — The  room  should  be  lighted  from  one  side  only,  or  by 


250 


PRACTICAL  SANITATION. 


Fig.    10. — The  Minnequa   Window  Curtain.       (Courtesy,   Dr.   R.   "W.  Corwin.) 


dD         (D 

1 

O 

d)         (ID 

« /'  — - 

0 

(D 

(D           (D 

- — 

-  /' 

' > 

Fig.    11. — Simple  wooden   holder  for  curtain   rods. 


SCHOOL   INSPECTION.  251 

properly  softened  slcy-lights,  and  the  lighting  area  should  not  be 
less  than  one-sixth  of  the  floor  area.  Prismatic  glass  in  the  upper 
sash  is  an  advantage,  since  it  diffuses  the  light  to  the  opposite  side 
of  the  room.  Sash  curtains  like  those  shown  in  the  cuts  (Figures 
10-11)  are  excellent  additions  to  any  window.  They  should  be  of 
washable  material,  with  the  rings  which  run  on  the  rods  attached 
permanently.  It  is  not  necessary  to  remove  the  rings  for  launder- 
ing. The  device  is  the  invention  of  Dr.  R.  W.  Corwin,  of  Pueblo, 
Colorado.  The  walls  should  be  a  pleasant  neutral  tint  of  gray 
tinged  with  yellow,  green,  red  or  blue.  They  should  never  be  a 
.  glaring  white  or  brilliant  color  of  any  kind,  A  greenish  gray  is 
perhaps  the  easiest  on  the  eyes,  but  except  in  sunny  climates  is  apt 
to  be  a  trifle  depressing  in  general  effect. 

Seating.- — Seats  must  be  adjustable  to  the  bodies  of  the  children. 
It  is  nothing  short  of  criminal  to  compel  the  child  to  adjust  itself  to 
the  seat.  Good  work  cannot  be  done  by  an  uncomfortable  child, 
and  lasting  eye-trouble  or  bodily  deformity  such  as  spinal  curvature 
may  come  from  the  practice. 

Blackboards. — These  should  be  always  dull-finished.  A  glossy 
blackboard  is  unnecessarily  hard  on  the  eyes.  Blackboards  and 
erasers  should  not  be  cleaned  while  school  is  in  session,  and  erasers 
should  be  dusted  outside.  The  chalk  racks  should  be  cleaned  each 
evening  by  the  janitor. 

Arrangement  of  Buildings. — It  is  beyond  the  province  of  this 
book  to  detail  the  principles  involved  in  all  the  various  depart- 
ments of  school  construction,  but  a  very  few  salient  points  will  be 
noted.  Every  school,  in  addition  to  the  requirements  before  men- 
tioned, must  be  so  arranged  that  it  can  readily  be  emptied  in  case 
of  fire.  To  this  end  doors  must  open  outward  and  never  be  locked 
while  school  is  in  session,  automatic  checks  being  preferable  to 
latches.  Stairs  must  be  broad  and  easy,  or  better,  inclined  planes 
or  ramps  be  provided,  thus  making  children  of  different  heights 
equal  in  the  matter  of  ascent  and  descent.  (Figures  12-13-14.) 
If  ground  is  not  prohibitively  high,  the  group  system  of  arrange- 
ment is  much  to  be  preferred  to  the  single  building  of  two  stories. 
A  height  of  two  stories  should  never  be  exceeded. 

The  subjoined  plan  for  a  grouped  system  of  school  buildings  is 
suitable  not  only  for  small  places  but  for  township  union  schools, 
and  besides  the  sanitary  advantages  which  are  obvious,  provides  a 
center  for  all  the  social  activities  of  the  surrounding  country  and 


252 


PRACTICAL   SANITATION. 


Fig.   12. — Patients  on   crutches  ascending  incline. 


^jjc.  -V'-'.  j^HBHHi^HHi^Bi..'.udH 


Fig.    13. — Man  ascending  fourteen-inch  step.  Fig.  14. — Compare  this  photograph  with 

The  child  a  seven-inch  step.      The   angle  that  .showing  men  on  the  incline  in 

at  the  knee  is  the  same.      In  practice  we  Pig.   12. 
make  the  three-foot  child  take  the  same 
step  as  the  six-foot  man. 

(Courtesy,   Dr.   R.  W.   Corwin.) 


SCHOOL   INSPECTION.  253 

permits  adequate  supervision  of  the  school  work  and  the  condition 
of  health  of  the  children. 

Care  of  Buildings. — Floors  may  be  oiled  with  a  small  amount  of 
floor  dressing.  Large  amounts  hinder  ready  cleaning  by  binding 
the  dirt.  Dry  sweeping  and  dusting  should  be  absolutely  pro- 
hibited, and  sweeping  and  dusting  of  corridors  should  not  be  per- 
mitted while  school  is  in  session.  Oiled  sawdust  is  a  good  allayer 
of  dust  and  is  prepared  by  dissolving  a  teacupful  of  floor  oil  in  a 
quart  of  gasoline  and  thoroughly  and  quickly  mixing  it  with  as 
much  sawdust  as  will  absorb  it  cleanly.  Oiled  dustcloths  are  made 
by  adding  an  ounce  of  floor  oil  to  a  quart  of  gasoline  and  wringing 
cloths,  which  are  best  yard-square  pieces  of  cheese  cloth,  out  of 
the  liquid.  These  are  allowed  to  dry  and  may  be  washed  when 
necessary.  On  account  of  the  inflammability  of  the  gasoline,  it  is 
necessary  that  these  operations  be  conducted  out  of  doors.  If 
electric  power  is  available,  the  use  of  a  vacuum  cleaner  is  a  great 
convenience  and  a  sanitary  device  to  be  commended.  Buildings 
should  be  scrubbed  out  at  least  weekly  on  Friday  evenings,  and 
before  the  beginning  of  the  school  year  should  have  a  most  thorough 
cleaning,  to  which  many  states  add  a  disinfection  by  sulphur,  for- 
maldehyd  or  a  liquid  disinfectant  applied  with  mop  and  spray. 

Inspection. — A  schedule  for  building  inspections  is  found  in  the 
Appendix. 

Teachers  and  Janitors. — No  teacher  or  janitor  should  be  em- 
ployed who  is  suffering  from  any  disease  which  would  debar  a  child 
from  the  school.  This  is  especially  true  of  tuberculosis  and  syphi- 
lis, and  school  medical  inspectors  and  health  officers  must  instantly 
require  the  resignation  of  any  person  employed  in  the  schools  who 
is  suffering  from  these  diseases. 

Pupils. — The  medical  inspection  of  schools  in  this  country  dates 
back  only  20  years,  but  in  Great  Britain  and  Germany  has  a  much 
earlier  origin.  It  is  now  required  in  many  states  in  some  or  all  of 
the  schools,  and  is  one  of  the  most  important,  if  not  the  most  im- 
portant, branches  of  sanitary  work.  The  Indiana  rules,  which  are 
most  recently  revised,  and  which  are  free  from  unnecessary  red 
tape  are  appended.  The  inspector  should  bear  in  mind  that  no 
amount  of  routine  work  will  take  the  place  of  intelligent  examina- 
tion of  the  children,  and  should  strive  to  make  and  keep  his  records 
complete. 


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254 


SCHOOL  INSPECTION.  255 


Physician's  Duties. 

Sec.  .'/.  School  physicians  shall  make  prompt  examination  and  diagnosis  of 
all  children  referred  to  them  and  such  further  examination  of  teachers,  jan- 
itors and  school  buildings  as  in  their  opinion  the  protection  of  the  health  of 
the  pupils  and  teachers  may  require.  Whenever  a  school  child  is  found  to 
be  ill  or  suffering  from  any  physical  defect,  the  school  physician  shall  promptly 
send  it  home,  with  a  note  to  parents  or  guardians,  briefly  setting  forth  the 
discovered  facts,  and  advising  that  the  family  physician  be  consulted.  If  the 
parents  or  guardians  are  so  poor  as  to  be  unable  to  give  the  relief  that  is 
necessary,  then  school  trustees  and  township  trustees,  as  the  case  may  be, 
sliall  provide  the  necessary  relief:  Provided,  That  in  cities  where  public  dis- 
pensaries exist  the  relief  shall  be  given  by  said  dispensaries.  School  physicians 
shall  keep  accurate  card-index  re'^ords  of  all  examinations,  and  said  records, 
that  they  may  be  uniform  throughout  the  State,  shall  be  according  to  the 
form  prescribed  by  the  rules  authorized  in  this  act,  and  the  method  and  manner 
of  reports  to  be  made  shall  be  according  to  said  rules :  Provided,  however, 
that  if  the  parents  or  guardian  of  any  school  child  sliall  at  the  beginning  of 
the  school  year  furnish  the  written  certificate  of  any  reputable  physician  that 
the  child  has  been  examined  and  parents  notified  of  the  results  of  such  ex- 
amination in  such  cases  the  services  of  the  medical  inspector  herein  provided 
shall  be  dispensed  with,  and  such  certificate  shall  be  furnished  by  such  parent 
or  guardian  from  time  to  time,  as  required  by  the  trustee  or  board  of  trustees 
having  charge  of  such  schools.  [From  the  Indiana  School  Inspection  Law 
of  1911.] 

Rules  for  Medical  School  Inspection. 

The  School  Physician. 

Rule  1.  It  shall  be  the  duty  of  the  school  physician  to  examine  all  school 
children  as  soon  as  practicable  after  their  first  admission  to  school.  This 
examination  shall  take  note  of  said  children  as  to  cleanliness,  obvious  physical 
defects,  as  physical  deformities,  condition  of  nose  and  throat,  and  teeth,  ear 
discharges,  squints,  general  fitness  for  school  life  and  previous  medical  history. 
Measurement  of  height  and  weight  shall  be  recorded.  This  first  examination 
shall  be  conducted  in  the  presence  of  the  parents  or  family  physician,  if  so 
desired.  (Provided,  that  any  child  presenting  a  certificate  of  examination  as 
provided  in  the  medical  inspection  law,  shall  be  exempt  from  the  school 
physician's  examination.)  A  permanent  record  of  all  such  examinations  shall 
be  kept  on  blanks,  according  to  form  prescribed  by  the  State  board  of  educa- 
tion and  State  board  of  health.  Such  records  to  be  subject  to  inspection  by 
the  public  only  on  an  order  from  the  school  physician. 

Rule  2.  It  shall  be  the  duty  of  the  school  physician  to  make  an  examina- 
tion of  all  children  referred  to  him  by  teachers.  Such  examination  to  consist 
of  whatever  may  be  necessary  to  determine  whether  or  not  the  child  should  be 
excluded  from  school.  Such  examination  shall  be  made  in  the  presence  of 
the  parents  if  so  desired.  In  all  matters  pertaining  to  exclusion  from  school 
the  decision  of  the  school  physician  shall  be  final.  A  record  shall  be  kept  of 
all  such  examinations  on  forms  shoMTi  in  this  manual,  to  be  provided  by  the 


256  PRACTICAL,   SANITATION. 

school  authorities,  a  copy  of  which  shall  be  furnished  the  parents  or  guardian 
of  said  children. 

Hule  3.  It  shall  be  the  duty  of  the  school  physician  to  make  a  general 
examination  of  all  the  children  in  the  public  schools  at  least  once  a  year  for 
any  defect  or  disability  tending  to  interfere  with  their  school  work,  and  a 
special  examination  of  children  (a)  who  show  signs  of  being  in  ill  health  or 
of  suffering  from  infectious  or  contagious  diseases  (b)  who  are  returning  to 
school  after  absence  on  account  of  illness  or  from  unknown  cause. 

Rule  Jf.  It  shall  be  the  duty  of  the  school  physician  to  make  such  examina- 
tions of  teachers,  janitors  and  school  buildings  as  in  his  opinion  the  protection 
of  the  health  of  the  pupils  may  require. 

Exiles  for  Teachers. 
The  teachers  in  all  the  public  and  parochial  schools  of  the  State  of  Indiana 
shall  test  the  sight  and  hearing  of  all  school  children  under  their  charge,  once 
in  each  school  year,  and  at  such  other  times  as  may  be  necessary.  The  sight 
test  shall  be  made  by  the  use  of  the  Snellen's  Test  Type  Chart  and  the  hearing 
test  shall  be  the  watch  test  or  the  whisper  test,  preferably  the  whisper  test. 
An  individual  record  shall  be  kept  of  said  test  and  whenever  a  defect  of  vision 
or  hearing  is  noted  the  case  shall  ie  referred  to  the  school  physician. 
Teachers  and  school  officials  shall  rigorously  exclude  from  school  all  children 
specified  in  any  notice  of  exclusion  issued  either  by  the  school  physician  or  by 
the  local  health  officer  until  such  children  shall  present  a  certificate  of  admis- 
sion from  the  school  physician  or  the  health  officer. 

Rules  for  Testing  Eyesight. 

Rule  1.  The  annual  test  for  eyesight  and  hearing  shall  be  made  as  early 
in  the  school  year  as  possible,  preferably  in  September.  Individual  pupils 
may  be  tested  at  any  time  that  a  test  is  considered  necessary. 

Rule  2.  All  tests  shall  be  made  as  nearly  as  possible  under  the  same  con- 
ditions and  shall  be  supervised  by  the  principal  or  superintendent,  in  order 
to  see  tbat  the  conditions  of  the  test  are  uniform  as  far  as  possible  for  the 
different  classes. 

Rule  3.  Do  not  expose  the  test  type  chart  except  when  in  use,  as  familiarity 
with  the  chart  leads  children  to  learn  the  letters  "by  heart."  Children  should 
be  examined  singly. 

Rule  .'i.  Test  each  eye  separately.  Have  the'  pupil  begin  at  the  top  of  the 
test  card  and  read  down  as  far  as  he  can,  first  with  one  eye  and  then  with  the 
other.  Hold  a  card  over  one  eye  while  the  other  is  being  examined,  but  do  not 
press  on  the  covered  eye,  as  pressure  may  produce  an  incorrect  examination. 

Rule  5.  Place  tbe  test  chart  on  the  wall  in  a  good  light  at  about  the  level 
of  the  pupil's  head  and  at  a  measured  distance  of  20  feet  from  the  pupil.  The 
chart  should  have  a  good  side  illumination  and  not  hang  in  range  of  a  window, 
which  will  dazzle  the  eyes. 

Rule  6.  Children  wearing  glasses  shall  be  tested  with  the  glasses  properly 
adjusted,  and  if  sight  is  found  normal  with  the  glasses  it  shall  be  recorded  as 
normal. 

Rule  7.  Record  as  defective  only  those  whose  vision  is  10/20  or  less  in 
either  eye. 


SCHOOL   INSPECTION.  257 

Rule  8.  Where  the  child  rannot  name  the  individual  letters,  although  able 
to  read,  the  chart  figures  may  be  used.  If  the  child  does  not  know  figures  or 
letters,  use  the  chart  of  inverted  E's,  asking  the  child  to  tell  by  the  movement 
of  the  hand  the  side  on  which  there  is  an  opening  on  the  E's,  i.  e.,  up,  down, 
right  or  left.   ■ 

Rule  9.  The  lines  on  the  chart  are  numbered  to  indicate  the  distance  the 
respective  letters  should  be  read  by  the  normal  eye.  The  record  is  made  by  a 
fraction,  of  which  the  numerator  represents  the  distance  of  the  chart  from  the 
child  and  the  denominator  the  lowest  line  he  can  correctly  read.  Thus,  if  at 
20  feet  the  pupil  reads  the  line  marked  20  feet,  the  vision  is  20/20  or  normal. 
If  he  only  reads  correctly  the  line  above  marked  30  feet,  his  vision  is  20/30 
or  2/3  normal.  If  at  a  distance  of  20  feet  the  pupil  can  only  read  correctly 
the  line  m.arked  40  feet,  the  vision  is  20/40  or  10/20,  which  must  be  recorded 
as  defective. 

If  a  pupil  cannot  read  the  largest  letters  he  must  go  slowly  toward  the 
chart  until  he  can.  The  distance  he  is  from  the  chart  when  he  can  read  the 
largest  letters  will  be  the  numerator  and  200  the  denominator. 

Rule  10.  Eeport  to  the  State  board  of  health  the  total  number  of  chil- 
dren examined  and  the  number  found  defective  in  eyesight  and  hearing  by 
test. 

Method  of  Testing  Hearing. 

The  person  conducting  the  test  should  be  possessed  of  normal  hearing.  The 
examination  should  be  conducted  in  a  room  not  less  than  25  feet  long  and 
situated  in  as  quiet  a  place  as  possible.  The  floor  should  be  marked  with 
parallel  lines,  one  foot  apart  and  numbered.  The  child  should  sit  in  a  re- 
volving chair  in  the  first  space.  Examination  should  be  made  with  the  whis- 
per or  spoken  voice.  Tlie  child  should  repeat  what  he  hears  and  the  distance 
at  which  words  can  be  heard  distinctly  should  be  noted.  The  two  ears  should 
be  tested  separately.  The  test  words  may  consist  of  numbers  from  one  to  one 
hundred  and  short  sentence.  It  is  best  that  but  one  pupil  at  a  time  be  allowed 
in  the  room,  to  avoid  imitation.  The  standard  to  be  adopted  is  as  follows: 
In  a  still  room  the  standard  whisper  can  be  heard  easily  at  25  feet.  The 
whisper  of  a  low  voice  can  be  heard  from  35  to  45  feet  and  of  a  loud  voice 
50  or  60  feet. 

In  the  watch  test  the  ticking  of  a  watch  is  used  instead  of  the  voice.  The 
watch  test,  however,  cannot  be  depended  upon  for  the  reason  that  children 
when  asked  if  they  hear  the  ticking  of  a  watch  will  answer,  "Yes,"  when  in 
fact  they  do  not  hear  the  watch.  For  this  reason  the  whisper  test  should  be 
used. 

Blank  Forms. 
The  following  blank  forms  are  recommended  for  use  in  connection  with  the 
institution  of  school  inspection,  in  order  that  the  system  of  supervision  and 
records  may  be  uniform  wherever  medical  inspection  is  established  throughout 
the  State.  Additional  blanks  and  forms  may  be  added  by  school  officials  to 
meet  local  conditions,  or  as  the  s"ope  of  medical  supervision  may  be  enlarged. 
The  forms  herein  given  will  be  found  essential  and  are  to  be  adopted  as  the 
basis  of  record  wherever  medical  inspection  is  instituted. 


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260  PRACTICAI/   SANITATION. 

No.  3. 

NOTE  TO  SCHOOL  INSPECTOR. 


.\  anw   

Residence    

t^eJiool    

Please  exaniine  iJiis  pupil  for 


.  Teacher. 


When   out  of   Blanks   notify. 


No.   4. 

School  Health  Department. 19 .  .  . 

TO  THE  PARENT  OR  GUARDIAN  OF 

It  is  my  duty  to  report  to  you  the  result  of  an  examination  of  the  above 
named. 


You  are  advised   to   take.. to  a  physician  for  further  advice  and 

treatment.     Be  sure  and 

TAKE  THIS  PAPER  TO  THE  DOCTOR. 

Medical  Inspector  of  Schools. 


No.  5. 


School. 19 . 


TO  THE  PARENT  OR  GUARDIAN. 
lixis  sent  home  Jroni  school  because 

the  child's  body  was  not  clean, 

the  head  was  not  clean, 

the  clothes  tvere  not  clean. 
The  child  must  not  be  sent  back  to  school  until  clean. 


.  Principal. 


No.  6. 


Department  of  School  Inspection. 

.  . Plblic  Schools.  19 . 


Principal : 
A  dmit 


Medical  Inspector. 


SCHOOL    INSPECTION.  261 

School  Health  Dkpartme>'t.         19 . .  . 

TO  THE  PARENT  OR  GUARDIAN 

of   

It  is  mil  (hiti/  to  report  to  you  that 

has  hern  examined  by  the  seliool  inspector — or  dentist — and  that 

teeth  need  cleaning — treatment — filling. 

Please  Sectre  Competent  Dental  Advice  at  Once. 

-. Teacher. 


School  Health  Department. 19 . .  . 

NOTICE  TO  PARENT  OR  GUARDIAN. 

You  are  hereby  notified  that 

has    been    examined    by    the   school    inspector   and   found    to    have   symptoms 
of    

Please  Secure  Competent  Medical  Advice  at  Once. 

Teacher. 


School  Health  Department.  19 . . 

NOTICE  TO  PARENT  OR  GUARDIAN. 

You  are  hereby  notified  that  the  school  examination  of 


ears 

shows    some    trouble    with    the  u-hich    needs    competent    medical    advice. 

eyes 

Please  Attend  to  This   at  Once. 
Teacher. 


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262 


CHAPTER  XXVII. 
FACTORIES  AND  WORKSHOPS. 

This  subject  may  or  may  not  form  an  important  part  of  the 
health  officer's  work,  accordingly  as  his  duties  are  defined  under 
the  statutes  of  his  particular  state.  Irrespective  of  the  visits  of 
state  factory  inspectors,  there  are  many  things  which  can  be  better 
attended  to  by  the  health  officer  himself,  since  he  is  or  should  be 
always  on  duty.  For  those  who  desire  to  make'  complete  inspections 
of  manufacturing  plants,  a  schedule  of  inspection  will  be  found 
in  the  Appendix.  In  the  limited  space  which  can  be  alloted  to  the 
subject  in  a  work  of  this  kind,  it  will  only  be  possible  to  indicate 
the  more  salient  points  for  investigation. 

Building. — This  should  be  well-lighted,  well-ventilated ;  provided 
with  outward-opening  doors;  fire-escapes  if  more  than  two  stories 
in  height;  have  a  water  supply  for  drinking  and  toilet,  as  well  as 
for  fire  extinguishing;  have  an  ample  cubic  space  for  each  worker. 
Seats  must  be  provided  for  women  workers  and  separate  toilets  for 
men  and  women. 

Lighting. — The  easiest  way  to  judge  of  the  lighting  of  a  building 
is  to  use  the  Snellen  test  cards.  If  a  given  line  only  can  be  read, 
while  the  observer  is  able  to  read  the  normal  in  proper  light,  then 
the  light  is  defective  just  that  much.  For  example,  if  the  inspector 
reads  in  a  good  light  the  20  foot  line  at  that  distance,  but  is  com- 
pelled to  go  to  a  distance  of  15  feet  to  read  it  in  the  factory,  the 
light  is  deficient  5/20  or  1/4.  This  may  be  due  to  insufficient  win- 
dow space  or  it  may  be  due  to  dirt  on  the  glass.  In  any  case  it  is  to 
be  corrected  because  it  is  conducive  to  diseases — especially  tubercu- 
losis, increases  the  liability  to  accidents,  and  is  ruinous  to  the  eyes 
of  operators  doing  fine  work. 

Ventilation. — With  a  mill  in  operation,  the  smoke  test  or  the  use 
of  essential  oils  is  out  of  the  question,  but  fortunately  it  will  then 
be  unnecessary.  Any  place  which  is  free  from  foul  odors  and  dust 
is  well-ventilated,  but  an  inspection  of  outlet  ducts,  and  force-  or 
exhaust-fans  will  enable  a  good  idea  to  be  formed  of  their  efficiency. 

263 


264  PRACTICAL   SAXITATIOX. 

Obstruetions  in  ventilators  should  always  be  looked  for.  The 
amount  of  dust  in  the  atmosphere  mar  be  ascertained  with  consid- 
erable a(M!iiracy  by  exposing  a  glass  plate  covered  \\ith  glycerine 
for  ten  minutes  and  then  counting  the  number  of  dust  specks  with 
a  linen  tester  in  a  good  light.  The  linen  tester  is  an  inexpensive 
lens  having  an  opening  of  either  one-fourth  or  one-half  inch  square, 
which  gives  a  convenient  field  for  this  kind  of  work.  Buildings 
having  metallic  dust,  especially  lead,  must  be  particularly  well- 
ventilated.  Those  having  grain-dust,  cotton  fibers,  fine  sawdust 
and  so  on,  are  subject  to  explosions  which  may  be  very  destructive. 
All  forms  of  dust  if  present  in  quantity  are  dangerous  to  health 
and  should  be  abolished  if  possible. 

Cubic  Space. — The  amount  of  cubic  space  per  worker  should 
never  be  under  the  250  cubic  feet  allowed  by  the  British  Factorj^ 
Act,  and  in  textile  and  other  dust^"  trades  should  be  at  least  double. 
In  fignring  space,  the  amount  taken  up  by  machinery  should  be 
deducted. 

Stairs  and  Fire  Escapes. — These  should  be  ample  to  allow  the 
emptying  of  the  factory  within  2  or  3  minutes,  even  if  a  part  of 
the  exits  should  be  cut  off.  In  large  buildings  a  central  length- 
wise partition  of  fireproof  material,  pierced  with  fire-proof  doors, 
enables  a  quick  escape  to  the  half  of  the  building  which  is  not  in 
danger,  whence  the  street  may  be  reached  at  leisure.  Elevators 
should  not  be  counted  in  as  fire-escapes,  since  elevator  shafts  are 
frequently  the  very  means  by  which  fire  is  drawn  to  upper  stories. 

Machinery. — All  belts,  line  shafts,  wheels,  pulleys  and  other 
moving  parts  must  be  guarded  so  as  to  be  as  nearly  "foolproof" 
as  possible.  So  also  should  chutes,  elevator  shafts  and  trapdoors 
be  protected. 

Toilets  and  Washrooins. — Toilets  and  washrooms  should  be  pro- 
vided for  each  sex.  and  should  be  properly  plumbed  with  open 
plumbing,  kept  in  good  order,  and  the  "s^'ashroom  supplied  with 
hot  and  cold  water,  soap  and  individual  towels.  Koller  towels  are 
too  frequently  a  means  for  the  transmission  of  disease.  If  cotton 
towels  are  used,  they  may  have  a  metallic  eyelet  which  threads  on 
an  arched  rod  which  is  locked,  and  which  allows  clean  towels  to  be 
taken  from  the  supply  on  top  and  after  use,  to  be  dropped  into  a 
receptacle  for  the  soiled  towels  below,  stiU  remaining  on  the  arch- 
rod.  Or  at  an  expense  less  than  that  of  laundrj'-,  paper  towels  can 
be  provided,  and  burned  after  use.     In  many  industries,  shower 


FACTORIES   AND    WORKSHOPS.  265 

baths  and  rest  rooms  would  greatly  add  to  the  efficiency  of  the 
workers,  and  in  some  places  are  provided.  If  they  are  in  use,  they 
should  be  inspected  also. 

Employees. — A  rather  cursory  examination  will  determine  how 
thoroughly  it  is  necessary  to  go  into  the  subject  of  occupational 
diseases.  If  an  old-established  factory  has  no  employees  who  have 
worked  more  than  a  few  years,  or  if  all  who  have  worked  more 
than  a  few  months  show  evidence  of  being  out  of  health,  the  whole 
establishment  should  be  gone  over  to  determine  the  cause. 

There  is  not  sufficient  available  space  to  go  thoroughly  into  the 
subject  of  occupational  diseases,  but  the  following  facts  should  be 
borne  in  mind : 

Dusty  Occupations  as  found  in  flour  mills,  cement  factories,  tex- 
tile mills,  grinding  establishments  and  similar  places,  are  prone  to 
cause  the  development  of  tuberculosis  in  the  workers. 

Metallic  Fumes,  causing  acute  or  chronic  poisoning,  are  asso- 
ciated with  zinc,  brass,  bronze  and  copper  smelting;  lead  working; 
mercury  works,  such  as  mirror  factories,  amalgamation  plants  and 
fire-gildiug  establishments.  The  dust  of  these  metals  also  acts  as 
do  the  fumes. 

Non-metallic  Fumes  and  Dust  which  are  also  associated  with 
specific  poisonings,  are  to  be  guarded  against  in  the  reduction  and 
smelting  of  the  precious  metals  (arsenic,  sulphur  and  its  com- 
pounds, tellurium  and  its  compounds,  cyanogen  compounds)  ;  phos- 
phorus works  and  match  factories  employing  white  phosphorus; 
chemical  works  and  dyeing  establishments.  Chronic  chromium  poi- 
soning may  be  caused  by  the  chromic  acid  or  chromates  used  in 
chrome  tanning. 

Methods. 

The  safest  plan  for  the  inexpert  investigator  to  employ  is  to  inves- 
tigate on  general  principles,  using  his  eyes  and  ears  and  any  local 
loiowledge  he  may  possess,  questioning  the  workers  under  seal  of 
confidence  when  out  of  the  factory,  reading  any  reports  or  text- 
books on  the  special  industry  under  investigation,  and  tinaUy  calling 
on  his  State  Board  of  Health  or  factory  inspection  or  both  for  as- 
sistance. By  so  doing  he  will  be  of  most  value  to  the  central 
authority  and  will  know  what  instructions  to  ask  and  what  course 
to  pursue  in  asking  assistance  or  authority. 

The  subject  of  occupational  diseases  is  exceedingly  important  to 


266  PRACTICAL   SANITATION. 

the  state  and  it  will  be  a  comparatively  easy  thing  for  the  health 
officer  to  qualify  to  handle  the  vocational  disabilities  found  in  his 
territory  and  thus  greatly  extend  his  usefulness.  On  the  other 
hand,  to  qualify  as  an  expert  in  all  the  occupational  diseases  re- 
quires years  of  study  and  observation  as  well  as  most  exceptional 
opportunities.  For  this  reason,  the  health  officer  is  urged  to  take 
every  chance  to  get  information  on  the  disabilities  attending  trades 
and  manufactures  in  his  own  district  rather  than  to  attempt  to 
cover  occupations  not  represented  in  his  territory. 


CHAPTER  XXVIII. 

INSTITUTIONS  AND  PEISONS. 

Since  people  are  confined  in  institutions  and  prisons  for  long 
periods  without  opportunity  to  see  the  outside  world,  and  since 
many  of  these  people  are  mentally  or  physically  ill,  the  asylum, 
prison  or  jail  must  be  kept  clean,  light  and  well  ventilated.  No 
defects  of  construction  can  excuse  or  condone  lack  of  cleanliness, 
and  if  construction  is  so  utterly  bad  that  cleanliness,  fresh  air  and 
ventilation  are  impossible,  then  steps  must  be  taken  for  condemna- 
tion of  the  unfit  building  and  its  replacement  by  a  new  and  decent 
one.  The  excellent  schedule  of  the  New  Jersey  Board  of  Health 
which  is  printed  in  full  in  the  Appendix  will  suggest  all  necessary 
details  in  the  inspection  of  such  places,  only  general  standards 
finding  a  place  in  this  chapter. 

Site. — The  site  of  any  public  charity  or  penal  institution  should 
be  chosen  on  well-drained  soil,  the  drainage  being  either  natural 
or  artificial  or  both.  This  soil  should  not  be  allowed  to  become 
polluted  by  refuse  or  filth  of  any  kind  and  if  the  pollution  has 
already  occurred  it  should  be  remedied  as  far  as  possible  by  remov- 
ing all  removable  filth  and  stopping  questionable  means  of  disposing 
of  it  for  the  future. 

Water  Supply. — The  water  supply  should  be  the  best  procurable. 
Wells,  unless  drilled  through  impermeable  rocks,  are  always  sus- 
picious and  if  used  must  be  frequently  examined  chemically  and 
bacteriologically.  Cisterns,  if  tight  and  properly  cared  for  are 
always  safe  against  anything  but  wilful  pollution.  A  good  public 
water  supply  is  best,  since  it  gives  water  under  pressure  at  all 
times,  although  the  same  advantages  can  be  obtained  anywhere  by 
the  use  of  power-pump  and  tank.  It  should  be  sufficient  to  allow 
frequent  bathing  and  afford  a  good  potable  water. 

Buildings. — These  should  be  well-lighted,  because  light  reveals 
dirt;  well  ventilated  and  airy,  and  have  not  less  than  750  cubic 
feet  of  space  for  each  inmate,  1,000  cubic  feet  being  a  better  and 
more  humane  allowance.     Temporary  crowding  below  this  require- 

267 


268  PRACTICAL   SANITATION. 

ment  should  never  be  allowed  to  become  permanent.  Inspection 
made  with  the  schedule  above  mentioned  in  hand  will  reveal  any 
faults  in  the  building. 

Plumbing  and  Drainage. — Storm-water  and  sewer  connections 
must  be  separate.  If  there  is  no  sewer  connected  with  the  insti- 
tution, sewage  and  slops  must  be  disposed  of  according  to  the 
principles  laid  down  in  Chapters  XXXII  and  XXXIII,  while  gar- 
bage is  cared  for  as  in  Chapter  XXXIV.  Baths  of  some  kind  must 
be  installed.  The  shower  or  rain  bath  is  most  easily  cared  for,  most 
effective  and  most  economical  of  water. 

Ventilation  and  Heating. — The  health  officer  will  be  able  to 
decide  these  questions  for  himself,  always  bearing  in  mind  that 
the  "jail  smell"  or  "institutional  odor"  is  an  evidence  of  bad 
ventilation  or  poorly  enforced  bathing  regulations,  or  both. 

Inmates. — The  inmates,  whether  the  institution  is  large  or  small, 
should  be  divided  not  only  as  to  sex,  but  as  to  age.  Old  and  hard- 
ened criminals  and  young  persons  just  entering  on  a  career  of 
crime  should  never  be  confined  together,  or  the  demented  placed 
in  with  criminals. 

There  should  be  provision  for  the  segregation  of  those  entering 
for  a  few  days,  until  it  can  be  ascertained  whether  they  are  suffer- 
ing from  vermin  or  infectious  diseases.  An  isolation  ward  is  an 
important  part  of  every  public  institution  of  any  size,  and  even 
the  smallest  should  have  a  separate  room  with  one. or  two  beds  for 
that  purpose.  It  is  an  excellent  rule  to  require  vaccination  at 
once  of  everyone  committed  to  a  public  institution  or  prison. 

Exercise  is  an  important  part  of  the  discipline  of  any  place  of 
this  kind,  and  a  place,  if  possible  in  the  open  air,  otherwise  in 
well  ventilated  corridors,  must  be  provided.  Unless  there  are 
grave  reasons  against  it,  writing  materials  and  reading  matter 
should  be  allowed  and  if  the  prisoners  or  patients  are  permitted 
to  be  together  for  recreation  at  any  time,  cards  and  other  harmless 
games  are  permissible. 

The  inmates  should  be  inspected  as  to  cleanliness  at  least  twice 
weekly,  and  better  daily  by  the  physician  or  a  disciplinary  officer. 

Infectious  Diseases. — These  are  always  to  be  handled  on  general 
principles,  isolation,  disinfection  and  immunization  where  that  is 
possible. 

Police. — Those  measures  taken  to  insure  cleanliness  of  any  build- 
ing or  grounds  are  in  military  parlance  "police  duty."     The  polic- 


IXSTITUTIOXS    AND    PRISONS.  269 

ing  should  be  done  every  day  in  the  year,  rain  or  shine,  especially 
if  done  by  the  inmates.  In  addition  to  the  daily  police,  white- 
washing should  be  done  frequenth^  enough  to  keep  all  surfaces 
spotless,  and  scrubbing  at  least  twice  a  week  should  keep  all  floors 
and  woodwork  in  perfect  order.  Inmates  who  wilfully  make  dirt 
or  commit  nuisances  should  be  compelled  to  clean  up  the  dirt  and 
may  be  further  iDuuished  by  deprivation  of  some  privilege  for  a 
time.  In  making  inspections  one  should  always  look  into  dark 
corners  which  may  conceal  sweepings,  scraps  of  food,  tobacco  cpiids 
and  spittle. 

Food. — The  only  way  to  know  what  the  inmates  actually  get  is 
to  be  present  in  the  wards  at  meal-time.  To  see  how  it  is  prepared, 
visit  the  kitchen.  The  ration  should  be  plain,  well-cooked  and 
sufficient.  Unless  the  inmates  are  employed  in  some  manner,  the 
ration  should  be  less  than  for  people  at  work.  Delicacies  are  out 
of  place  except  for  the  sick,  the  aged,  and  on  Sundays  and  holidays. 

Opportunity. — The  institutional  or  jail  physician  has  an  oppor- 
tunity to  do  more  than  the  ordinary  sanitary  work  and  by  careful 
study  of  his  patients  and  charges  may  do  more  than  anyone  else 
toward  reclaiming  them  toward  useful  lives. 


CHAPTER  XXIX. 
THE  RAT. 

Sanitary  Importance. — The  rat  is  of  importance  to  sanitarians 
because  of  its  agency  in  the  transmission  of  bubonic  plague,  and  no 
text-book  of  sanitation  can  be  considered  complete  which  does  not 
give  attention  to  the  rat  and  the  best  means  of  destroying  it. 
Slaughter-house  rats  are  also  the  chief  means  of  infecting  hogs 
with  trichinosis,  a  disease  of  considerable  importance. 

Species. — The  common  rat  is  the  brown  or  Norway  rat  {Mus 
norvegicus),  though  two  others,  the  black  rat  {Mus  rattus)  and  the 
roof  rat  {Mus  alexandrinus)  are  found  in  the  United  States.  All 
of  these  are  accidentally  introduced  denizens  of  the  Old  World, 
the  last  named  two  being  first  introduced,  and  being  driven  out 
by  the  hardier  and  stronger  brown  rat,  which  is,  next  to  man  and 
the  dog,  the  most  cosmopolitan  of  all  mammals. 

The  rat  occasions  an  annual  economic  loss  by  destruction  of 
property  amounting  to  many  millions  of  dollars  in  the  United 
States  alone.  "With  this  loss,  as  sanitarians,  we  have  nothing  to 
do,  but  of  course  the  methods  noted  in  the  following  pages  have 
equal  value  for  anyone  wishing  to  destroy  rats,  whether  for  sani- 
tary or  economic  reasons.  They  are  condensed  from  Farmers' 
Bulletin  No.  369,  of  the  United  States  Department  of  Agriculture, 
which  is  the  work  of  Mr.  David  E.  Lantz,  of  the  Biological  Survey. 
Those  who  wish  a  fuller  account  of  the  rat  than  is  here  possible 
will  do  well  to  procure  this  bulletin. 

The  first  consideration  in  a  warfare  on  rats  is  collective  action 
by  the  entire  community.  Action  by  individuals,  while  it  destroys 
a  small  portion  of  the  rat  population,  simply  results  in  driving 
them  to  new  haunts  for  a  time,  to  return  later  in  their  original 
numbers.  Intermittent  persecution  has  bred  in  the  rat  a  high  de- 
gree of  intelligence  and  cunning  which  make  anything  but  well- 
concerted  plans  of  little  force. 

Rat-proof  Building. — The  most  important  means  of  repressing 
rats  is  to  deprive  them  of  safe  breeding  places.     This  is  best  done 

270 


THE   RAT.  271 

by  the  free  use  of  concrete  in  foundations,  in  cellar  floors,  around 
drain  pipes,  and  wherever  rats  are  likely  to  try  to  find  an  entrance. 
For  this  purpose  a  medium  rather  than  a  lean  concrete  should  be 
used.  The  use  of  concrete  between  lath  and  weather-boarding  in 
frame  houses,  to  the  height  of  a  foot,  will  prevent  them  from  get- 
ting in  except  through  open  doors  and  windows.  Old  rat  holes 
can  be  stopped  up  with  a  mixture  of  concrete  and  broken  glass  or 
crockery.  Basement  windows  must  be  screened.  Inner  doors, 
forming  a  vestibule  are  a  safeguard,  and  outer  doors,  particularly 
to  markets  and  groceries,  should  be  guarded  with  pieces  of  thin 
metal  to  prevent  rats  from  gnawing  through  at  night. 

Concrete  should  replace  brick  or  wood  for  porch  and  area  floors, 
and  stables,  barns  and  granaries  should  be  of  the  same  material. 
In  the  actual  or  threatened  presence  of  bubonic  plague,  it  is  neces- 
sary to  compel  the  tearing  down  of  all  old  buildings  which  can 
harbor  rats,  as  under  such  circumstances  they  become  dangerous 
nuisances. 

Where  concrete  floors  are  used  in  horse-  and  cow-stables,  they 
may  be  covered  with  wood,  in  order  to  prevent  the  chilling  contact 
of  the  first  material,  and  where  it  is  used  for  the  floors  of  poultry 
houses,  it  may  be  covered  with  dry  earth  or  sand.  It  must  be 
emphasized  that  every  rat  destroys  property  on  an  average  of  some- 
thing like  a  dollar  a  year,  and  that  the  man  who  has  no  rats  on 
his  premises  is  the  gainer  by  the  fact.  As  concrete  is  now  as  cheap 
as  or  cheaper  than  wood  for  many  purposes,  its  use  should  be  en- 
couraged as  far  as  possible. 

Starving  Out  Rats. — Rats  are  the  most  omnivorous  of  all  ani- 
mals, and  while  it  is  important  for  economic  reasons  to  keep  food 
intended  for  consumption  by  man  or  domestic  animals  away  from 
rats,  it  is  equally  important  to  destroy  garbage  so  that  they  cannot 
live  on  it  in  the  interim  between  their  attacks  on  really  valuable 
stores.  If  garbage  is  handled  as  described  in  the  chapter  on  the 
subject,  rats  will  not  be  able  to  get  at  it.  To  the  extent  that  their 
food  supply  is  cut  off,  their  reproduction  is  limited.  Wherever 
possible,  the  collection  of  garbage  and  its  disposition  should  be 
done  by  the  municipality,  and  everywhere  it  should  be  a  matter 
of  care  that  no  rats  get  access  to  it  either  before  or  after  collection. 
Country  slaughter-houses  are  probably  the  worst  offenders  in  this 
regard,  the  rats  being  treated  like  beneficent  scavengers.  In  fac- 
tories, the  remains  of  lunches  should  be  carefully  collected  into 


272  PRACTICAL   SANITATION. 

metal  receptacles  and  afterwards  burned,  as  hungry  rats  are  more 
easily  trapped  than  well-fed  ones. 

AVire  netting,  of  heavy  half -inch  mesh,  placed  around  the  outside 
of  iceboxes,  cooling-rooms  and  similar  places,  renders  them  en- 
tirely rat-proof.  Strips  of  thin  metal  on  all  the  angles  of  boxes 
prevent  rats  from  gaining  entrance,  since  they  never  attempt  to 
enter  from  a  plane  surface,  but  always  from  a  salient  angle. 

Natural  Enemies  of  Rats. — The  most  important  natural  enemies 
of  the  rat  are  the  larger  hawks  and  owls,  skunks,  foxes,  coyotes, 
weasels,  minks,  dogs,  cats  and  ferrets. 

Whenever  the  farmer  or  the  sportsman  is  tempted  to  destroy  one 
of  the  predatory  animals  named  above,  he  should  consider  that  the 
occasional  chicken  or  game-bird  taken  by  them  is  far  out-weighed 
by  the  number  of  rats  they  destroy,  the  rats  in  turn  destroying 
more  eggs,  game  and  poultry  than  all  of  these  agencies  combined, 
to  say  nothing  of  the  other  property  they  injure  and  destroy. 

Traps. — The  traps  figured  are  those  found  to  be  most  effective  by 
the  Biological  Survey.  Owing  to  their  cunning,  rats  are  hard  to 
trap  in  large  numbers  and  for  long  periods  of  time,  especially  if 
food  is  abundant;  but  properly  handled,  traps  are  one  of  the  most 
effective  means  of  reducing  their  numbers. 

Guillotine  Traps. — For  general  use  these  traps  (Figure  16) 
are  probably  best,  since  they  occupy  little  space,  and  may  be  used 
with  bait ;  or  unbaited,  set  in  runs  or  against  rat-holes.  The  sim- 
plest designs,  and  those  made  of  metal,  are  best,  on  account  of 
superior  durability  and  less  capacity  to  absorb  odors.  Fried  sau- 
sage or  bacon  is  one  of  the  best  baits,  and  part  of  an  ear  of  corn, 
if  other  grains  are  not  stored  near,  makes  a  good  bait.  The  trigger 
wire  should  be  bent  back,  as  shown  in  cut,  so  that  the  released 
spring  will  strike  the  rat  squarely  across  the  neck. 

Other  good  baits  are  oatmeal,  toasted  cheese,  buttered  toast,  fish, 
fish  offal,  fresh  liver,  raw  meat,  pine  nuts,  apples,  carrots,  corn,  and 
sunflower,  squash  or  pumpkin  seeds.  Broken  fresh  eggs  are  always 
effective,  and  fresh  vegetables  are  very  tempting  to  rats  in  winter. 
When  seed  or  meal  is  used  with  this  kind  of  trap,  it  is  sprinkled 
on  the  trigger  plate,  or  if  the  trap  is  unprovided  with  a  plate,  the 
trigger  wire  is  bent  outward  and  the  bait  placed  underneath. 

Cage  Traps. — If  rats  are  numerous,  the  cage  trap  if  of  heavy 
wire  and  well  reeiiforccd,  can  be  used  to  advantage.  Lightly  con- 
structed cage  traps  allow  the  rat  to  force  his  way  out  between  the 


THE    RAT.  273 

wires.  They  should  be  baited  and  left  open  for  several  nights, 
until  the  rats  are  accustomed  to  enter  to  obtain  food.  They  should 
then  be  closed  and  baited,  when  a  large  catch  may  be  expected — 
especially  of  young  rats.  As  many  as  25  rats  and  even  more  have 
been  taken  at  a  time  in  these  traps. 

It  is  sometimes  a  good  idea  to  place  cage  traps  under  a  bunch 
of  hay  or  straw,  and  to  place  a  decoy  rat  in  the  trap  is  often  useful. 
Another  good  idea  is  to  put  the  opening  of  the  trap  to  the  inside 
of  a  rat-hole  in  a  large  packing  case,  the  case  then  being  filled  with 
trash. 

Cage  traps,  notwithstanding  occasional  large  catches,  are  less 
effective  in  the  long  run  than  guillotine  traps. 

FiGURE-4  Trigger  Trap. — This  type  of  trap  is  familiar  to  every 
boy  who  has  lived  in  the  country,  and  the  principle  is  applicable 
either  to  the  box  or  deadfall  of  flat  stone  or  weighted  plank.  In 
the  latter  form  it  will  sometimes  take  a  wise  old  rat  who  refuses 
to  enter  the  more  modern  forms  of  trap. 

Steel  Trap. — The  steel  trap  (No.  0  or  1)  may  sometimes  be 
used,  but  as  the  animal  may  be  caught  by  the  foot  and  not  killed, 
its  squealing  may  frighten  away  other  rats  temporarily.  It  may 
be  set  in  a  shallow  pan  and  covered  with  bran  or  oats,  taking  care 
that  the  bait  does  not  get  under  the  trigger  pan.  This  may  be 
prevented  by  placing  a  very  light  piece  of  cotton  underneath  the 
trigger,  and  setting  as  lightly  as  possible.  In  narrow  runs  an 
unbaited  steel  trap,  covered  with  tissue  paper  or  thin  cloth  is  some- 
times good. 

To  be  effective,  the  bait  must  always  be  of  a  kind  not  readily  to 
be  procured  by  rats;  in  a  feed  store  or  granary,  use  meat;  in  a 
meat  market,  grain  or  vegetables.  The  bait  must  be  kept  fresh 
and  attractive,  and  no  other  store  of  the  kind  used  must  be  accessible. 

Barrel  Traps. — These  traps  are  easily  made  by  covering  a  head- 
less barrel  with  coarse  brown  paper  and  baiting  for  several  nights. 
A  cross  is  then  cut  in  the  paper,  and  the  bait  secured  by  gluing  or 
tying  so  that  the  bait  will  not  follow  the  rat  into  the  barrel.  As 
many  as  3,000  rats  have  been  caught  in  such  traps  in  a  single 
warehouse  in  one  night.  A  similar  trap  consists  of  a  barrel  with 
a  light  hinged  cover,  so  weighted  as  to  swing  back  to  the  horizontal 
after  the  rat  has  been  dropped  into  the  barrel.  Both  plans  are 
shown  in  Figure  17. 

Pit  Traps. — These  are  illustrated  in  Figure  18,  and  consist  of 


274 


PRACTICAL  SANITATION. 


Fig.   16. — Method  of  baiting  guillotine  ti'ap. 


Fig.   17. — Barrel   traps:      1,   witli   stiff  paper  cover;   2,  with  hinged  barrel  cover; 

o,  stop;    b,  baits. 


THE    RAT. 


275 


a  simple  box  with  a  light  wood  or  metal  cover  in  two  sections,  so 
hung  on  rods  that  they  swing  back  to  position  after  the  weight  of 
the  rat  is  removed.  They  are  intended  to  be  sunk  in  runways,  or 
around  barnyards,  haystacks  and  the  like,  so  that  the  top  is  flush 
with  the  ground,  and  may  be  used  with  or  without  bait.  They  are 
effective  placed  along  the  fence  outside  a  poultry  yard,  and  pro- 
tected with  a  shelter  of  brush  or  boards. 


Fig.   18. — Pit  trap. 


aa,  Rat  run;   &&,  cover;  cc,  position  of  weights;   dd,  rods  on  which 
cover  turns. 


Fence  and  Battue. — In  the  Orient,  heaps  of  straw  and  litter 
are  placed  in  the  fields  and  left  for  several  days  until  rats  are  at- 
tracted there  in  numbers.  A  portable  bamboo  fence  is  then  set  np 
around  it,  men  and  dogs  enter,  and  the  straw  is  then  thrown  over 
the  fence.  This  method  is  useful  at  the  removal  of  grain,  hay  or 
straw  stacks,  fine  wire  netting  being  substituted  for  the  bamboo 
fence.  Useless  piles  of  brush  may  be  set  on  fire  and  dogs  used  to 
catch  the  rats  as  they  run  out. 

Poisons. — Poisons  are  the  best  and  quickest  way  to  get  rid  of 
rats — especially  if  they  are  present  in  numbers,  but  on  account  of 
the  odor  are  not  desirable  around  dwellings  or  food  shops.  They 
may  be  used  most  effectively  around  barns,  corn  cribs,  sheds,  stables 
and  similar  outbuildings.  The  various  poisons  will  be  named  and 
described  in  detail. 

Barium  Carbonate. — This  is  very  cheap  and  effective  against 
both  rats  and  mice,  and  has  the  advantage  of  having  neither  taste 
nor  smell.  It  is  corrosive  to  the  mucous  lining  of  the  stomach, 
and  in  sufficient  quantity  is  dangerous  to  larger  animals,  but  in  the 
dose  fatal  to  rats  and  mice  is  devoid  of  action.  It  is  a  slow  poison, 
and  if  there  is  an  exit  provided  they  usually  go  outside  in  search 
of  water.  It  is  best  made  into  a  dough  with  4  parts  of  flour  by 
weight  or  8  parts  of  oatmeal  by  bulk,  using  sufficient  water  to  mix. 


276  PRACTICAL   SANITATION, 

It  may  also  be  spread  on  moistened  toasted  bread,  fish  or  bread  and 
butter.  The  prepared  bait  should  then  be  scattered  about  the  rat 
runs,  a  teaspoonful  at  a  place.  If  a  single  application  fails  to 
kill  or  drive  away  all  rats,  it  should  be  repeated  with  a  change  of 
bait. 

Strychnine. — This  is  a  rapid,  cheap  and  effective  poison.  It 
should  be  used  in  the  form  of  the  sulphate.  The  dry  crystals  may 
be  inserted  into  bits  of  raw  meat,  Vienna  sausage  or  toasted  cheese, 
and  these  placed  in  rat  runs  or  burrows,  or  oatmeal  may  be  mois- 
tened with  a  strychnine  syrup,  made  as  follows :  Dissolve  one-half 
ounce  of  strychnine  sulphate  in  a  pint  of  boiling  water,  add  a  pint 
of  thick  sugar  syrup  and  stir  thoroughly.  Smaller  quantities  may 
be  prepared  in  the  same  proportion.  Care  must  be  taken  to  moisten 
all  the  oatmeal  or  grain  with  the  syrup,  and  grain  is  more  effective 
if  left  overnight  to  soak  in  it. 

Arsenic  is  a  favorite  rat-poison  owing  to  its  apparent  cheapness, 
but  owing  to  the  smaller  dose  of  strychnine  required,  the  latter  is 
really  cheaper.  Arsenic  varies  considerably  in  its  effect  on  rats 
and  a  rat  which  has  recovered  from  arsenic  poisoning  will  rarely 
take  the  bait  again.  It  may  be  used  with  any  of  the  baits  hereto- 
fore described  under  the  first  two  paragraphs. 

Phosphorus  is  used  almost  as  widely  as  arsenic,  but  owing  to  the 
danger  of  burning  person  or  property  is  not  recommended  by  the 
Biological  Survey,  hence  its  use  will  not  be  described  here. 

CAUTION! — Since  the  laying  of  poison  on  one's  own  lands  is 
not  usually  regulated  by  law  in  the  United  States,  their  use  should 
be  even  more  guarded.  Only  in  a  few  Western  states,  where  poison 
is  used  for  the  destruction  of  other  animals,  is  notice  to  one's 
neighbors  necessary,  but  if  poison  is  to  be  spread  where  it  can  affect 
any  of  a  neighbor 's  stock,  it  is  only  common  justice  that  he  shall 
be  duly  informed.  This  applies  particularly  to  arsenic  and  strych- 
nine on  meat,  since  valuable  dogs  may  thus  be  unintentionally 
poisoned. 

Poison  in  Poultry  Houses. — If  poison  is  to  be  put  where  poultry 
is  kept,  it  is  best  placed  inside  of  a  small  box,  on  the  bottom  and 
near  the  middle.  Over  this  a  considerably  larger  box  is  inverted. 
Both  boxes  have  two  or  more  openings  sufficiently  large  to  admit 
rats  to  the  poison,  but  small  enough  to  exclude  poultry  or  other 
animals  than  rats  or  mice. 

Domestic  Animals. — Dogs. — Dogs  are  by  far  the  best  ratters 


THE   RAT.  277 

among  domestic  animals.  The  small  breeds,  quick  and  active,  as 
the  terriers,  or  small  mongrels,  if  trained  and  intelligent,  are  won- 
derfully destructive  to  rats,  and  may  be  relied  on  to  keep  the 
premises  reasonably  free  of  rats. 

Cats  are  over-rated  as  rat  destroyers,  and  are  usually  too  well-fed 
and  lazy  to  relish  the  hard  fights  necessary  to  kill  full-grown  rats. 
They  prefer  mice  and  birds  as  more  savory  and  easily  caught,  but 
do  some  service  in  killing  young  rats. 

Ferrets  like  minks  and  weasels  are  inveterate  foes  of  rats.  They 
follow  the  rat  into  his  burrow,  and,  unless  muzzled,  kill  him  and 
suck  the  blood,  often  lying  by  the  kill  for  hours.  They  are  best 
used  to  chase  rats  out  of  the  burrows  into  the  open  where  they  can 
be  killed  by  dogs.  Dogs  intended  to  work  with  ferrets  must  be 
quiet,  and  the  dogs  and  ferrets  must  be  accustomed  to  each  other. 
Ferrets  must  be  carefully  guarded  against  escape,  as  if  allowed  to 
run  wild,  they  would  be  very  destructive. 

Fumigation. — Carbon  Bisulphide  (bisulphide  of  carbon)  may 
be  used  to  destroy  rats  in  their  burrows  in  fields,  along  river  banks, 
levees  and  similar  places,  by  saturating  a  piece  of  cotton  in  the 
liquid,  forcing  it  into  the  burrow  and  then  stopping  the  opening 
with  wet  earth  to  prevent  the  vapor  from  escaping.  The  rats  and 
any  other  animals  in  the  burrow  are  asphyxiated.  As  the  vapor 
of  carbon  disulphide  is  very  inflammable,  care  must  be  taken  not  to 
handle  it  near  a  flame. 

Chlorine,  carbon  monoxide,  sulphur  dioxide,  and  hydrocyanic 
acid  are  also  used  for  the  destruction  of  rats  in  uninhabited  build- 
ings. It  is  necessary  for  their  successful  use  that  the  building 
should  be  sufficiently  tight  to  confine  the  gas  until  it  has  had  time 
to  penetrate  to  the  haunts  of  the  rats.  Each  has  its  special  draw- 
backs. Chlorine  is  a  powerful  bleaching  agent.  Sulphur  dioxide, 
if  formed  by  the  combustion  of  sulphur  in  open  pans  or  kettles,  is 
apt  to  cause  fires  unless  very  carefully  handled,  and  is  also  a  bleach. 
Carbon  monoxide  is  odorless  and  if  the  building  should  be  incau- 
tiously entered  before  the  gas  had  escaped  might  cause  death.  Hy- 
drocyanic acid  destroys  all  animal  life,  but  on  account  of  its  highly 
poisonous  nature  should  be  used  only  with  the  greatest  caution. 
Full  directions  for  the  employment  of  sulphur  and  hydrocyanic 
acid  will  be  found  in  the  chapter  on  Disinfection,  page  58.  All 
of  these  poisons  are  alike  open  to  the  objection  of  doing  their  work 
too  well.     Too  large  a  number  of  rats  and  other  vermin  are  de- 


278  PRACTICAL   SANITATION. 

stroyed  at  once,  and  the  resultant  stench  is  apt  to  make  the  place 
unapproachable. 

Micro-organisms. — Several  "rat-viruses"  consisting  of  bacteria 
pathogenic  to  rats  but  not  to  other  animals  are  on  the  market.  The 
Biological  Survey  does  not  recommend  them,  on  account  of  their 
uncertain  action  and  expense. 

Organized  Action. — In  this  lies  the  key  of  the  whole  situation. 
If  boys  and  young  men  can  be  interested  in  the  sport  of  killing  rats 
their  numbers  can  be  greatly  reduced  and  the  consequent  danger 
of  the  propagation  of  plague,  should  it  be  introduced,  will  be  mini- 
mized. Competition  stimulated  by  appropriate  prizes  offered  for 
efforts  lasting  over  a  considerable  time  will  result  in  the  training 
of  the  boys  in  methods  of  rat-hunting  and  in  the  breeding  and 
training  of  dogs  which  will  hunt  and  kill  rats,  whether  with  their 
masters  or  not.  In  the  presence  of  plague  it  will  be  necessary  to 
employ  paid  rat-catchers,  operating  under  the  special  methods  ap- 
plicable to  that  situation. 

The  following  summary  is  taken  verbatim  from  the  bulletin  be- 
fore mentioned: 

SUMMARY  OF  RECOMMENDATIONS. 

The  following  are  important  aids  in  limiting  the  numbers  of  rats  and  re- 
ducing the  losses  from  their  depredations: 

1.  Protection  of  our  native  hawks,  owls,  and  smaller  predatory  mammals — 
the  natural  enemies  of  rats. 

2.  Greater  cleanliness  about  stables,  markets,  grocery  stores,  warehouses, 
courts,  alleys,  and  vacant  lots  in  cities  and  villages,  and  like  care  on  farms 
and  suburban  premises.  Tliis  includes  the  storage  of  waste  and  garbage  in 
tightly  covered  vessels  and  the  prompt  disposal  of  it  each  day. 

.3.  Care  in  the  construction  of  buildings  and  drains,  so  as  not  to  provide 
entrance  and  retreats  for  rats,  and  the  permanent  closing  of  all  rat  holes  in 
old  houses  and  cellars. 

4.  The  early  thrashing  and  marketing  of  grains  on  farms,  so  that  stacks 
and  mows  shall  not  furnish  harborage  and  food  for  rats. 

5.  Removal  of  outlying  straw  stacks  and  piles  of  trash  or  lumber  that 
harbor  rats  in  the  fields. 

6.  Uat-proofing  of  warehouses,  markets,  cribs,  stables,  and  granaries  for 
storage  of  provisions,  seed  grain,  and  feedstufTs. 

7.  Keeping  effective  rat  dogs,  especially  on  farms  and  in  city  warehouses. 

8.  The  systematic  destruction  of  rats,  whenever  and  wherever  possible,  by 
la)  trapping,  (b)  poisoning,  and  (c)  organized  hunts. 

9.  The  organization  of  rat  clubs  and  other  societies  for  systematic  warfare 
against  rats. 


THE   RAT.  279 

The  Indiana  legislature  of  1913  passed  a  law  which  is  now  in 
effect  delegating  to  health  officers  the  power  to  compel  rat  extermi- 
nation and  to  enter  upon  any  premises  for  that  purpose.  The  pres- 
ence or  threat  of  disease  is  not  necessary  for  such  action.  This  law 
also  allows  the  proclamation  of  "Rat  Extermination  Days"  either 
in  municipalities  or  statewide.  Public  sentiment  has  not  yet  com- 
pelled or  permitted  an  adequate  use  of  this  law,  which  is  probably 
the  first  of  the  kind  in  the  country. 


CHAPTER  XXX. 
ANTI-FLY  CAMPAIGNS. 

Sanitary  Importance. — For  ages  the  common  house-fly  was  re- 
garded as  a  pest  but  nothing  more ;  a  nuisance  to  be  borne  with  each 
recurring  warm  season,  but  harmless  aside  from  the  annoyance  of 
its  buzzing  and  tickling,  and  its  habit  of  committing  suicide  in  food, 
or  depositing  its  eggs  or  droppings  therein. 

But  observations  multiplied  of  septic  diseases,  anthrax,  hospital 
gangrene,  septicemia,  and  localized  septic  infections  either  known 


Fig.  19. — The  Poliomyelitis  Fly.     The  stable  fly  or  biting  house  fly  (Stomoxys  calcitrans)  : 
Adult,  larva,  puparium,   and  details.     All  enlarged.      (L.  O.  Howard.) 

(Prom  Farmers'   Bulletin   No.   459,   U.    S.   Department   of  Agriculture.) 

to  be  conveyed  by  the  mandibles  of  biting  flies  or  the  feet  of  sucking 
flies,  or  suspected  to  be. 

Here  the  matter  rested  until  the  latter  part  of  the  summer  of 
1898,  when  the  Vaughan-Shakespeare  board  began  its  investigations 
of  the  terrible  typhoid  epidemics  which  had  raged  in  the  concen- 
tration camps  at  Chickamauga  and  elsewhere,  with  a  morbidity  rate 
of  approximately  20  per  cent  of  all  troops  present.  Before  that 
time,  typhoid  fever  had  been  considered  to  be  always  a  water-borne 
disease,  but  the  water  was  here  found  in  most  instances  to  be  per- 

280 


ANTI-FLY    CAMPAIGNS. 


281 


feetly  good,  at  least  at  its  source.  Early  in  their  investigation  they 
found  that  flies  with  feet  covered  with  lime  from  the  sinks  and 
latrines  were  crawling  over  the  food  in  the  kitchens  and  mess-tents. 

Diseases  Carried. — By  cultivating  the  filth  from  the  feet  and 
droppings  of  these  flies,  the  typhoid  organism  was  recovered  in  a 
number  of  instances.  Later  experiments,  and  the  additional  experi- 
ence of  the  British  in  South  Africa,  have  fully  confirmed  these  con- 
clusions, and  have  added  a  number  of  other  diseases  which  are 
either  known  or  are  strongly  suspected  to  be  conveyed  in  the  same 
manner.  These  include  cholera,  cholera  nostras,  dysentery,  both 
amebic  and  bacillary,  tuberculosis,  the  putrefactive  diarrheas,  and 
may  reasonably  be  suspected  to  include  smallpox,  scarlet  fever  and 
measles.  Later  observations  still,  tend  to  show  that  the  virus  of 
anterior  poliomyelitis  may  be  conveyed  in  the  same  manner. 

The  Typhoid  Fly. — Chapin  is  not  inclined  to  ascribe  the  impor- 
tance to  the  fly  which  is  usually  ascribed  to  it,  but  the  writer  had 
the  opportunity  to  trace  out  a  small  epidemic  three  years  ago  in 


Fig.  20. — One  of  the  Typhoid  Flies.  The  little  house  fly  (Homalomyia  brevis)  : 
at  left ;  male  next,  with  enlarged  antenna ;  larva  at  right.  All  enlarged. 
Howard. ) 

(From  Farmers'  Bulletin  No.  459,   U.   S.  Department  of  Agriculture.) 


Female 
(L.   O. 


which  every  other  cause  could  be  excluded  definitely,  and  a  probable 
source  was  found  in  a  filthy  open  privy  vault  from  which  the  infec- 
tion could  readily  have  been  carried  by  flies  to  every  person  who 
was  infected.  This  little  epidemic  of  20  cases  had  a  mortality  of 
20  per  cent,  and  all  the  cases  were  of  severe  type.  It  disappeared 
at  once  after  the  expiration  of  the  usual  incubation  period  of  two 
weeks,  on  the  cleaning  and  closure  of  the  vault. 

Military  sanitarians  ascribe  great  importance  to  the  fly  as  a  trans- 


282  PRACTICAL   SANITATION. 

mitter  of  disease,  and  it  is  a  fact  that,  since  the  introduction  of 
incinerators  and  flyproof  latrines,  typhoid  has  ahnost  entirely  dis- 
appeared as  a  post-maneuver  disease.  This  is  not  due  to  antity- 
phoid inoculation,  since  comparatively  few  of  the  organized  militia 
troops  have  submitted  to  protective  vaccination.  It  is  not  in  the 
least  intended  that  the  importance  of  the  fly  as  a  carrier  of  typhoid 
and  similar  diseases  shall  be  magnified  at  the  expense  of  food  and 
water  infection,  carriers  and  contact  infection,  or  other  proved 
method  of  transmitting  disease,  but  only  to  point  out  that  in  small 
places  where  open  privies  abound,  the  fly  must  be  taken  into  account 
as  a  probable  factor. 

Classiiication. — A  discussion  of  the  systematic  nomenclature  and 
morphology  of  the  flies  would  be  out  of  place  here,  beyond  the  state- 
ment that  the  flies  are  all  members  of  the  order  Diptera,  the  Two- 
winged  Insects,  and  comprise  many  species,  genera,  and  several 
families  of  biting  or  suctorial  insects,  all  of  which  are  to  be  guarded 
against  in  the  same  way. 

With  this  brief  resume  of  the  fly  as  a  disease  carrier,  the  impor- 
tance of  the  subject  to  the  health  officer  becomes  at  once  apparent. 

Fortunately  for  the  human  race,  the  fly  has  a  number  of  natural 
enemies,  in  the  shape  of  birds,  other  insects,  and  vegetable  parasites 
— particularly  fungi,  which  tend  to  keep  down  their  numbers,  which 
would  otherwise  render  life  impossible  or  at  least  unbearable. 

Life  History. — Flies  breed  with  great  rapidity.  Each  adult  fe- 
male fly  deposits  several  hundred  eggs  during  her  life,  and  in  favor- 
ably warm  weather,  the  entire  cycle  from  the  egg,  through  the  pupa 
or  maggot,  to  the  imago  or  adult,  takes,  in  the  common  house-fly 
but  8  days.  Unfavorable  conditions  may  lengthen  this  period  to 
10  or  11  days,  but  since  the  increase  is  geometrical  in  ratio,  it  is 
easy  to  see  the  immense  numbers  to  which  the  progeny  of  a  single 
female  may  reach  in  the  course  of  a  season,  without  natural  or  arti- 
ficial checks.  The  genesis  of  the  swarms  that  infest  our  streets  and 
houses  is  thus  manifest. 

Prevention  of  Breeding. — Since  flies  breed  only  in  filth,  the  first 
thing  to  do  is  to  render  it  impossible  for  the  fly  to  reach  any  of  the 
accumulations  unavoidable  around  habitations. 

This  is  done : 

1.  By  destroying  filth  wherever  found. 

2.  By  rendering  it  distasteful  or  poisonous  to  flies  or  their  larvae 
by  the  use  of  lime,  kerosene,  oil  of  pennyroyal  or  cresol. 


ANTI-FLY    CAMPAIGNS.  283 

3.  By  excluding  light  from  the  receptacle,  or  by  screens  which 
the  flies  cannot  pass. 

The  most  difficult  part  of  an  anti-fly  campaign  is  teaching 
the  people  to  dispose  of  their  garbage  properly.  The  subject  of 
garbage  disposal,  being  treated  in  a  special  chapter,  will  not  be  dis- 
cussed here,  but  it  is  to  be  noted  that  no  amount  of  screening, 
trapping  or  poisoning,  will  make  up  for  careless  disposal  of  filth 
and  waste.  All  such  materials  rmist  be  promptly  destroyed  or 
buried. 

Lime,  applied  in  powder,  is  neither  very  distasteful  nor  damaging 
to  the  adult  fly,  and  if  air-slacked,  not  at  all.  If  a  really  good  sus- 
pension of  milk  of  lime  (calcium  hydrate)  is  mixed  with  the 
garbage  or  refuse,  the  eggs  and  pupa  or  maggots  of  the  fly  are  at 
once  destroyed,  but  it  must  be  made  to  come  in  contact  with  the  eggs 
or  maggots  to  do  any  good.  Kerosene  oil  is  more  effective,  but  more 
expensive.  Where  crude  oil  or  low-grade  distillates  are  procurable, 
the  expense  is  much  lessened.  Oil  of  pennyroyal,  in  the  proportion 
of  1  ounce  to  1  quart  of  kerosene,  is  very  distasteful  to  the  adult  fly, 
as  well  as  fatal  to  the  young,  and  a  small  quantity  sprinkled  around 
the  garbage  can  is  sufficient  to  keep  away  all  flies.  The  greatest 
drawback  is  the  expense.  Cresol  is  not  expensive,  and  may  be  used 
freely  in  2  per  cent  emulsion. 

Privy  vaults,  manure  bins  and  similar  places  must  be  made  and 
kept  perfectly  dark.  Flies  are  pre-eminently  light-seeking  insects, 
and  greatly  abhor  dark  places.  Screens  may  be  made  to  answer 
the  same  purpose,  but  to  be  effective  must  be  made  automatically 
self-closing,  otherwise  they  are  sure  to  be  left  open  and  to  fail  of 
their  object. 

Fly  Poisons. — Poisons  for  flies  are  of  different  classes.  Most  of 
the  proprietary  ones  are  arsenical.  Formaldehyd  in  dilute  solution 
has  been  often  recommended,  but  is  only  a  pleasant  intoxicant  and 
not  a  poison,  A  sweetened  1 :1000  solution  of  corrosive  sublimate 
is  cheap  and  good. 

Any  of  these  poisons  must  be  put  where  children  cannot  get  them. 
They,  like  the  small  traps  mentioned  later,  are  most  useful  when 
set  in  an  otherwise  darkened  room,  by  a  partly  lighted  and  partly 
opened  window,  in  a  light  current  of  air,  and  must  be  placed  in 
shallow  dishes.     Poisons  are  not  recommended  for  indoor  use. 

Fly  Traps. — The  most  successful  way  of  destroying  adult  flies 
is  by  the  use  of  traps,  of  which  there  are  several  good  makes  on  the 


284  PRACTICAL   SANITATION. 

market,  all  employing  the  very  old  principle  of  an  outer  cone  or 
cylinder  of  wire  gauze,  with  an  inner  cone  of  the  same  material 
having  an  opening  at  the  point.  The  apparatus  is  supported  on 
short  legs  a  short  distance  above  the  floor  or  table,  or  has  a  false 
bottom  with  a  marginal  opening  which  permits  the  flies  to  enter. 


Fig.  21. — Wire  gauze  fly  traps. 

It  is  baited  with  bread  and  milk,  molasses  and  vinegar,  stale  egg  or 
spoiled  banana.  The  flies  seek  the  bait  and  on  attempting  to  fly, 
rise  into  the  upper  cone  through  the  opening  in  the  lower  one  and 
are  unable  to  And  their  way  back. 

In  the  smaller  traps,  the  flies  are  killed  by  scalding  or  holding 
for  a  minute  over  a  flame,  but  in  the  larger  ones  are  allowed  to  die 
of  crowding,  the  dead  ones  being  shaken  out  through  a  door  in  the 
bottom  and  the  live  ones  flying  to  the  top.  The  small  traps  are  in- 
tended for  indoor  use  or  for  attachment  to  garbage  cans,  and  the 
larger  are  set  outside  on  the  street.     The  large  traps  have  been 


ANTI-FLY    CAMPAIGNS.  285 

loiown  to  catch  100,000  in  a  couple  of  days.  For  the  benefit  of 
anyone  wishing  to  see  how  effectively  the  trap  is  working,  it  may 
be  stated  that  2,500  house-flies  weigh  one  ounce. 

Fly  Paper. — For  killing  the  last  remnants  of  swarms  in  the 
house,  sticky  fly-papers  are  invaluable,  as  they  catch  both  germ  and 
fly.  The  following  formula  is  recommended  for  its  manufacture: 
Rosin,  2  parts,  castor  oil,  1  part  (by  weight)  ;  boil  in  a  kettle  until 
of  the  consistency  of  thick  molasses  and  spread  on  any  kind  of 
paper.  The  remainder  may  be  put  into  a  fruit  jar  until  wanted. 
In  boiling,  it  must  be  remembered  that  the  mixture  is  inflammable. 
The  careful  housewife  also  uses  the  "swatter"  to  advantage. 

The  use  of  screens  is  necessary  to  keep  out  flies  blown  or  coming 
from  other  places,  but  cannot  be  depended  on  to  exclude  them  com- 
pletely, unless  doors  are  closed  with  a  screened  vestibule,  having  an 
outer  and  an  inner  screened  door,  closing  automatically.  This  ar- 
rangement is  to  be  recommended  for  hospitals,  restaurants  and 
other  places  where  it  is  imperative  to  keep  out  all  flies. 

Since  flies  are  known  to  fly  at  least  half  a  mile  with  favoring 
winds,  it  is  evident  that  anti-fly  work  to  be  effective  must  be  en- 
forced over  as  large  areas  as  possible.  The  good  results,  if  obtained, 
are  reached  by  a  ceaseless  campaign  of  publicity  in  newspapers 
and  by  placards,  and  by  the  employment  of  a  sufficiently  large  and 
intelligent  sanitary  police  force.  Aside  from  the  securing  of  an 
adequate  and  healthful  water  supply,  no  other  measure  will  so  im- 
prove the  public  health  and  decrease  the  sickness  and  death-rates, 
especially  among  children. 


CHAPTER  XXXI. 
THE  MOSQUITO. 

Sanitary  Importance. — The  sanitary  importance  of  the  mosquito 
was  first  brought  home  to  the  American  profession  by  the  excellent 
work  of  the  Reed  Yellow  Fever  Commission  in  1900-1901,  which 
demonstrated  the  connection  between  the  Stegomyia  mosquito  and 
that  disease.  That  discovery  has  led  to  extensive  anti-mosquito 
campaigns  in  almost  every  civilized  country,  not  only  for  the  sup- 
pression of  yellow  fever,  but  for  the  control  of  malaria,  dengue  and 
filariasis,  all  of  which  are  mosquito-borne  diseases.  The  most  bril- 
liant and  successful  of  these  campaigns  have  been  those  in  Cuba, 
beginning  in  1900,  and  that  in  the  Canal  Zone,  which  was  begun  in 
1905  and  continues  to  the  present. 

Classification. — Mosquitoes  compose  the  family  Culicidce  of  the 
order  of  Diptera,  the  Two-winged  Insects.  They  are  subdivided 
into  two  sub-families — the  AnopJielines  and  the  CuUoines.  The 
principal  genus  from  a  sanitary  standpoint,  of  the  first  sub-family, 
is  the  genus  Anopheles,  of  which  a  number  of  species  are  known  to 
be  malaria  carriers;  while  the  Culicines,  which  comprise  among 
other  genera,  Culex,  whose  species  distribute  dengue  and  filariasis, 
and  Stegomyia,  the  yellow  fever  mosquito.  The  generic  and  spe- 
cific differences  among  these  insects  are  too  small  to  be  recognized 
by  the  unskilled  observer,  and  will  be  omitted  here.  There  is  one 
very  obvious  mark,  however,  which  distinguishes  the  Anophelines 
from  the  Culicines,  the  position  when  at  rest.  The  Culicines  when 
at  rest  keep  the  body  nearly  parallel  to  the  surface  on  which  they 
stand,  while  the  Anophelines  stand  out  at  an  angle  of  45  degrees, 
and  have  the  appearance  of  standing  on  their  heads.  The  note  of 
the  Anopheles  is  also  lower-pitched  than  that  of  Culex,  and  it  is 
more  apt  to  fly  silently.     Only  female  mosquitoes  bite. 

Life  History. — The  eggs  of  mosquitoes  are  tiny  cylinders  less 
than  a  millimeter  in  length,  and  one-sixth  to  one-fourth  of  that  in 
width,  wh  ch  are  deposited  in  clear  still  water  almost  anywhere. 
Anopheles  will  also  deposit  the  eggs  in  running  water  among  the 

286 


THE    MOSQUITO. 


287 


weeds  that  are  submerged  along  the  banks.  The  eggs  vary  in  num- 
ber from  20  to  75  or  more,  and  in  Culex  are  deposited  in  a  single 
boat-shaped  mass,  while  the  other  genera  mentioned  divide  them 


Pig.  22. — Anopheles   mosquito;    adult  female;    enlarged.      (After   Howard.) 


Fig.  23. — Resting  position  of  Anopheles  and  Culex  mosquitoes 


(After  Howard.) 


by  twos  and  threes.  They  may  remain  floating  or  may  be  sub- 
merged without  much  influence  on  future  development.  Drying 
for  considerable  periods  can  also  be  sustained  with  only  partial 


288  PRACTICAL   SANITATION. 

damage,  and  some  species  are  also  able  to  withstand  a  good  deal  of 
cold,  while  on  the  other  hand  the  typical  yellow  fever  mosquito, 
8.  fasciata,  has  its  development  much  interfered  with  or  stopped 
entirely  by  even  moderate  cold.  The  development  of  mosquitoes  is 
most  rapid  when  the  temperature  is  75°  or  over,  at  which  point  the 
complete  development  from  the  egg  to  the  perfect  adult  is  passed 
through  in  from  11  to  18  days. 

There  are  two  stages  which  intervene  between  the  egg  and  the 
adult  insect,  the  larva  or  "wiggletail"  and  the  pupa  or  chrysalis. 
The  larval  stage  is  familiar  to  everyone  who  has  observed  small  col- 
lections of  stagnant  water  and  watched  the  actively  swimming  and 
t^nsting  embryos.  The  pupal  stage  is  passed  attached  to  some  con- 
venient object,  and  after  the  lapse  of  from,  2  to  5  or  6  days,  the 
mosquito  emerges,  leaving  the  cast  skin  behind. 

Natural  Enemies. — In  anti-mosquito  campaigns,  the  larvas  are 
the  point  of  attack,  although  most  of  the  measures  which  destroy 
the  larvae  will  destroy  pupae.  The  adult  mosquitoes  are  too  mobile 
to  be  readily  attacked  except  by  fumigation,  a  process  which  is  alto- 
gether too  expensive  except  for  the  immediate  neighborhood  of  in- 
fected houses.  Fortunately  we  have  the  assistance  of  many  natural 
enemies  in  fighting  against  mosquitoes.  The  larvas  and  pupae  are 
eaten  by  fishes  of  many  of  the  smaller  kinds  and  by  tadpoles,  and 
the  adults  are  caught  by  many  birds,  dragon-flies,  toads,  frogs  and 
lizards.  Some  of  these  we  are  enabled  to  enlist  as  regulars  in  the 
war,  as  for  instance  certain  fishes  are  placed  in  ponds,  drainage 
ditches  and  so  on,  with  a  view  to  killing  off  the  larvee,  while  the 
presence  of  swifts  and  swallows  around  houses  is  often  encouraged 
for  the  same  reason. 

Drainage. — The  great  remedy  against  mosquitoes  is  proper  drain- 
age and  clearing  up  by  every  necessary  means  all  collections  of 
useless  and  stagnant  water.  Next  to  this  is  proper  protection  of 
needed  water  collections  as  tanks,  cisterns  and  reservoirs  by  appro- 
priate means. 

It  is  not  necessary  to  have  a  large  amount  of  water  for  mosquitoes 
to  breed.  An  old  tin  can,  a  gutter  spout,  the  fork  of  a  tree  or  any- 
thing which  will  hold  enough  water  not  to  evaporate  entirely  before 
rain  falls  again,  will  breed  mosquitoes.  Therefore,  in  beginning 
work  against  mosquitoes,  the  starting  place  must  be  the  clearing 
of  all  localities  near  dwellings  of  their  accumulated  tin  cans,  broken 
bottles,  empty  jugs  and  the  like,  and  the  clearing  out  and  making 


THE    MOSQUITO.  289 

secure  of  all  house  gutters.  Then  all  pools  on  the  ground  must  he 
filled  up  or  drained,  after  which  one  is  ready  to  begin  on  the  larger 
problems  involved.  In  draining  areas  of  any  size,  it  will  be  neces- 
sary to  have  the  services  of  an  engineer  to  lay  off  levels  and  lay- 
out the  ditches,  but  small  places  can  generally  be  disposed  of  by 
merely  clearing  and  deepening  the  natural  runway  by  which  the 
overflow  gets  away.  These  ditches  must  be  clear-cut  and  sharp, 
and  once  made  must  be  kept  clear  of  vegetation.  If  the  pond 
is  too  large  to  drain,  it  may  be  cleaned  around  the  edges  and 
have  minnows  or  other  fish  placed  in  it  or  be  covered  with  a  film 
of  crude  petroleum,  which  will  cjuiekly  kill  both  larvae  and  pu- 
pa?. This  treatment  is  also  good  for  cesspools  and  privy  vaults, 
but  a  better  is  to  abolish  them.  Roof -tanks,  cisterns  and  water 
used  for  domestic  purposes  must  be  screened  with  a  fine-mesh 
screen. 

Anti-mosquito  Work. — Anti-mosquito  work  can  only  be  done 
well  if  done  systematically,  by  trained  men,  acting  under  ample 
authority.  There  must  be  a  responsible  head  who  directs  all  the 
work.  He  must  be  provided  with  a  map  of  the  territory  to  be 
gone  over,  and  must  route  his  inspectors  so  that  they  cover  it  abso- 
lutely thoroughly.  The  work  of  draining,  cleaning  up  and  so  on 
cannot  well  be  done  by  the  municipality  in  many  cases  on  account 
of  the  cost,  but  orders  can  be  issued  designating  the  measures  to 
be  taken,  as  outlined  in  the  foregoing  paragraphs,  and  after  the 
expiration  of  the  time,  the  inspectors  will  make  their  investigation, 
point  out  defects  to  householders  and  issue  specific  orders  under 
penalty  of  prosecution.  A  second  inspection  is  then  necessary  to 
see  that  the  orders  have  been  carried  out,  and  subsequent  inspec- 
tions at  intervals  to  see  that  the  original  conditions  have  not  re- 
curred. 

Such  a  campaign  as  this  is  usually  only  made  in  threatened  or 
actual  epidemics  of  yellow  fever,  but  might  well  be  undertaken  for 
severe  epidemics  of  malaria.  Short  of  this,  some  good  can  be  done 
by  educating  the  people  to  the  fact  that  mosquitoes  are  not  only  a 
nuisance  but  disease  carriers,  and  that  any  mosquitoes  found  in 
their  houses  are  usually  bred  within  100  yards  of  the  place.  Short 
talks  to  school  children  are  good  means  of  getting  ideas  on  mos- 
quito and  fly  extermination  into  the  homes  of  the  people,  while 
newspaper  publicity  can  often  be  had  free  and  always  for  a  consid- 
eration.    Campaigns  of  education  may  grow  into  the  more  serious 


290  PRACTICAL    SANITATION. 

and  formal  measures  recommended  in  the  last  paragraph  and  in 
any  event  are  not  to  be  despised. 

Very  extensive  anti-mosquito  work  has  been  done  by  many  Ameri- 
can cities,  notably  New  York,  the  New  Jersey  cities,  and  New 
Orleans.  Much  of  this  has  been  done  against  the  voracious  and 
annoying,  but  otherwise  harmless  Salt-water  Mosquito,  Culex 
solUcitans,  with  the  result  that  the  other  mosquitoes  have  also  been 
diminished.  The  Southern  cities  in  general  have  been  watchful 
against  the  Stegomyia,  and  yellow  fever  is  now  but  little  dreaded 
in  consequence. 

Fumigation. — Should  the  destruction  of  adult  mosquitoes  become 
necessary  it  may  be  accomplished  by  the  use  of  sulphur  fumigation 
of  all  parts  of  the  house  simultaneously,  using  2i/^  lbs.  per  1,000 
cubic  feet,  or  1  lb.  of  pyrethrum  for  the  same  area;  in  the  latter 
case,  the  fumes  of  the  burning  pyrethrum  only  stupefy  the  insects 
and  after  an  hour's  exposure  they  must  be  swept  up  and  burned. 

The  following  additional  suggestions  are  from  Bulletin  No.  444. 
Department  of  Agriculture,  by  Dr.  L.  0.  Howard: 

MIMMS  CULICIDE. 

This  mixture  is  made  of  equal  parts  by  weight  of  carbolic  acid  crystals  and 
gum  camphor.  The  acid  crystals  are  melted  over  a  gentle  heat  and  poured 
slowly  over  the  gum,  resulting  in  the  absorption  of  the  camphor  and  a  final 
clear,  somewhat  volatile  liquid  with  an  agreeable  odor.  This  liquid  is  per- 
manent, and  may  be  kept  for  some  time  in  tight  jars.  Volatilize  3  ounces  of 
this  mixture  over  a  lamp  of  some  Idnd  for  every  1,000  cubic  feet  of  space. 
A  simple  apparatus  for  doing  this  may  be  made  from  a  section  of  stovepipe 
cut  so  as  to  have  three  legs  and  an  outlet  for  draft,  an  alcohol  lamp  beneath 
and  a  flat-bottom  basin  on  top.  Tlie  substance  is  inflammable,  but  the  vapor 
is  not  explosive.  The  vapor  is  not  dangerous  to  human  life  except  when  very 
dense,  but  it  produces  a  headache  if  too  freely  breathed.  Rooms  to  be  fumi- 
gated should  be  made  as  nearly  air-tight  as  possible. 

OTHER  FUMIGANTS. 

According  to  Dr.  .Jolin  B.  Smith,  powdered  jimson  \\eed{Datiira  stramonium) 
can  be  burned  to  advantage  in  houses.  He  recommends  8  ounces  to  fumigate 
1,000  cubic  feet  of  space.  He  states  that  it  should  be  made  up  by  the 
druggist  into  an  amount  with  niter  or  saltpeter  1  part  to  3  of  Datura,  so 
as  to  burn  more  freely.  He  states  that  the  fumes  are  not  poisonous  to  human 
beings,  are  not  injurious  to  fabrics  or  to  metals,  and  can  be  used  with  entire 
safety.     He  suggests  that  it  be  burned  in  a  tin  pan  or  on  a  shovel. 

The  burning  of  dried  orange  peel  has  been  recommended  as  a  deterrent 
against  mosquitoes  by  a  .Japanese  physician. 


THE    MOSQUITO.  21)1 

APPARATUS  FOR  CATCHING  ADULT  MOSftTIITOES. 

An  interesting  homemade  apparatus  in  common  use  in  many  parts  of  tlie 
United  States  is  very  convenient  and  effective.  It  consists  of  a  tin  cup  or  a 
tin  can  cover  nailed  to  the  end  of  a  long  stick  in  such  a  way  that  a  spoonful 
or  so  of  kerosene  can  be  placed  in  the  cup.  whi'^'h  may  then,  by  means  of  the 
stick,  be  pressed  up  to  the  ceiling  so  as  to  inclose  one  mosquito  after  another. 
When  covered  over  in  this  way  the  captured  mosquito  will  attempt  to  fly  and 
be  caught  in  the  kerosene.  By  this  method  perhaps  the  majority  of  the 
mosquitoes  in  a  given  bedroom — certainly  all  of  those  resting  on  the  ceiling — 
can  be  caught  before  one  goes  to  bed. 

Mr.  H.  Maxwell-Lefroy,  of  India,  makes  a  trap  consisting  of  a  wooden  box 
lined  with  dark-green  baize  and  having  a  hinged  door.  The  trap  is  12  inches 
long,  12  inches  broad,  and  9  inches  deep.  A  small  hole,  covered  by  a  revolving 
piece  of  wood  or  metal,  was  prepared  in  the  top  of  the  box.  Owing  to  the 
liabit  of  mosquitoes  to  seek  a  cool,  shady  place  in  which  to  rest,  such  as  a 
dark  corner  of  the  room  or  a  book  shelf,  or  something  of  that  sort,  they  will 
enter  the  trap,  which  is  put  in  the  part  of  the  room  most  frequented  by  mos- 
quitoes, all  other  dark  places  being  rendered  uninhabitable  so  far  as  possible. 
They  are  driven  out  of  book  shelves  with  a  duster  or  with  tobacco  smoke,  and 
go  into  the  desirable  sleeping  place  for  the  day.  The  door  is  then  closed  and 
fastened,-  and  into  the  small  hole  at  the  top  of  the  box  a  teaspoonful  or  less 
of  benzine  is  introduced.  This  kills  all  of  the  mosquitoes  inside,  and  the  box 
is  then  thoroughly  aired  and  replaced.  In  this  way  Mr.  Lefroy  is  very  suc- 
cessful in  catching  mosquitoes.     At  one  time  he  averaged  83  a  day. 


CHAPTER  XXXII. 
PREVENTION  OF  SOIL  POLLUTION. 

THE  SANITARY  PRIVY.^ 

Soil  Pollution. — Soil  pollution  is  the  surest  evidence  of  a  state  of 
savagery  or  barbarism.  Its  prevention  is  the  price  which  civiliza- 
tion, which  gathers  men  into  cities  and  towns,  must  pay  for  health 
in  its  citizens  and  for  its  own  very  existence.  No  sensible  farmer 
would  pasture  his  stock  or  rear  poultry  year  after  year  on  the 
same  soil  without  expecting  to  pay  for  his  carelessness  with  heavy 
loss.  The  explanation  is  simple — that  the  excreta  of  all  animals 
contain  within  them  parasites,  animal  or  bacterial,  which  accumu- 
late in  the  soil  until  the  health  of  the  stock  or  poultry  can  no 
longer  be  maintained  on  account  of  continuing  infection  and  rein- 
fection. 

Savage  and  barbarous  men  avoid  this  for  their  flocks  and  herds 
and  themselves  by  frequent  migrations,  which,  while  they  perhaps 
have  their  root  in  superstitious  notions,  serve  to  give  a  relative 
immunity  from  the  effects  of  soil  pollution.  More  than  4,000  years 
ago  Moses  prescribed  a  method  for  disposing  of  human  excreta 
that  is  still  followed  in  military  practice,  with  slight  elaboration. 
Military  surgeons  with  marching  commands  so  well  understand  the 
dangers  of  soil  pollution  that  even  after  a  camp  of  a  single  night, 
the  sinks  are  carefully  closed  and  their  positions  marked  so  that  they 
are  not  likely  to  be  reopened  in  case  of  a  return  to  the  same  site. 
Such  being  the  case,  how  can  we  expect  to  have  a  satisfactory 
degree  of  public  health  in  a  town  where  pictures  like  that  of  Figure 
24  continually  obtrude  themselves  on  the  eye  and  nostrils? 

Disease  Transmission. — The  diseases  most  commonly  transmitted 
thi-ough  pollution  of  the  soil  by  human  excreta  are  typhoid  fever, 
hoohirorni,  di/senferi/,  botli   bacillary  and   amel)ic,  asiatic  cholera, 


^  For  a  complete  disrussion  of  this  topic,  with  working  plans  complete  for  the  construc- 
tion of  the  sanitary  privy,  see  Public  Health  Bulletin  No.  37,  Public  Health  and  Marine 
Hospital  Service,  "  The  Sanitary  Privy,"  by  Ch.  Wardell  Stiles,  Ph.D.,  Professor  of 
Zoology,  Hygienic  Laboratory,  from  which  the  text  of  this  chapter  is  largely  abstracted 
and  the  illustrations  borrowed. 

292 


PREVENTION   OF   SOIL   POLLUTION. 


293 


tape-worms,  summer  diarrhea,  eel-worm  infection,  and  very  possibly 
the  exanthemata. 

The  popular  idea  of  a  privy,  as  indicated  by  its  name,  is  a 
place  where  the  demands  of  nature  may  be  satisfied  with  due 
regard  to  privacy.  Stiles  very  properly  defines  it,  from  a  sanitary 
standpoint,  as  "An  outhouse  designed,  primarily,  to  prevent  soil 


Fig.  24. — How  NOT  to  built  a  privy.      (Courtesy,  Indiana  State  Board  of  Healtli.) 

pollution  and  hence  to  prevent  the  spread  of  disease  through 
dissemination  of  disease  germs  contained  in  the  excreta ;  secondarily, 
to  insure  privacy  and  safeguard  modesty  to  persons  responding  to 
the  daily  calls  of  nature." 

According  to  this  definition,  the  essential  part  of  the  privy  is 
a  receptacle  which  will  safeguard  the  contents  against  dissemina- 
tion by  any  and  all  agents,  as  for  instance,  rain,  insects  (flies,  etc.), 


294 


PRACTICAL   SANITATION. 


chickens,  swine,  dogs,  etc.  Secondly,  it  should  provide  a  retiring 
room  for  the  people  responding  to  nature's  calls.  While  this 
second  part  is  not  absolutely  essential,  it  is  desirable,  since  if  the 
privy  is  a  comfortable  place  for  that  purpose,  other  places  are 
not  so  apt  to  be  sought,  and  the  fecal  accumulations  are  all  in  one 


Fig.  2.3. — Xoli-  tlic  daii(4f)-  to  walcr  .siipijly  and  the  pussibili lits  of  lly  and  mosquito  infection 
from  tliis  and  the  preceding  examples.      (Courtesy,  Indiana  State  Board  of  Health.) 

place  where  they  can  be  properly  disposed  of,  instead  of  being 
scattered  all  over  the  farm,  in  the  woods,  the  fields  and  the  barn. 

The  points,  then,  to  be  considered  in  the  construction  of  a 
sanitary  privy  are: 

1.  The  provision  of  a  proper  receptacle  for  the  protection  of  the 
excreta  from  all  agencies  which  may  spread  the  contained  germs. 


PREVENTION    OF    SOIL   POLLUTION.  295 

2.  To  make  the  outhouse  so  comfortable  that  it  will  be  sought 
in  preference  to  any  other  place. 

3.  To  make  it  in  such  a  way  that  the  poorest  citizen  can  afford  it. 
How  NOT  to  Build  a  Privy. — Figure  24  shows  a  privy  which 

not  only  outrages  the  senses,  but  is  a  menace  to  health.  Figure  25 
is  not  so  great  an  offender  against  the  sense  of  sight  and  better 
answers  the  demands  of  decency,  but  is  not  a  whit  better  in  the 
matter  of  sanitary  needs.  The  night-soil  simply  overflows  upon 
the  ground,  to  be  carried  by  rain,  wind,  flies  and  animals  in  all 
directions.  Such  privies,  even  if  cleaned  daily,  are  a  public  danger, 
but  the  man  who  is  so  benighted  as  to  build  an  abomination  of  this 
kind  ordinarily  never  cleans  it.  Any  one  who  has  been  at  all ' 
familiar  with  this  type  of  outhouse  knows  the  swarms  of  flies  that 
gather  about  it  in  warm  weather,  and  the  poultry  and  swine  feed 
upon  its  filth.  Such  a  privy  on  a  dairy  farm  should  condemn  it 
absolutely  till  a  proper  closet  is  substituted,  on  account  of  the 
danger  from  typhoid  fever  and  other  filth  diseases. 

How  to  Build  a  Privy. — This  subject  is  of  so  great  importance 
in  town  and  rural  sanitation  that  Dr.  Stiles'  description  and 
specifications  which  represent  the  best  solution  of  the  problem  yet 
devised,  are  reprinted  complete,  both  for  single  privies  for  dwellings 
and  larger  ones  for  hotels  and  schools.  The  general  use  of  such 
privies  in  towns  not  supplied  with  sewerage  systems  and  in  the 
country  would  practically  wipe  out  typhoid  fever,  hookworm, 
dysentery  and  other  diseases  having  a  like  mode  of  transmission. 
The  conscientious  sanitarian  cannot  do  otherwise  than  urge  and 
force  their  use  to  the  best  of  his  ability. 

How  to  build  a  privy. —  Figures  26  and  27  show  a  privy  designed  to  comply 
with  the  revised  definition  given  above.  The  following  are  the  essential  fea- 
tures: There  is  (A)  a  closed  portion  (box)  under  the  seat  for  the  reception 
(in  a  receptacle)  and  safeguarding  of  the  excreta;  (B)  a  room  for  the  occu- 
pant; and   (C)   there  is  proper  ventilation. 

A.  The  receptacle  consists  practically  of  a  box,  with  a  top  represented  by 
the  seat,  with  a  foor  wliich  is  a  continuation  of  the  floor  of  the  room,  with  a 
front  extending  from  the  seat  to  the  floor,  with  a  hinged  hack  which  should 
close  tightly,  and  with  two  sides  continuous  with  the  sides  of  the  room  and 
provided  with  wire  screened  ventilators,  the  upper  margin  of  which  is  just 
under  the  level  of  the  seat.  The  seat  should  have  one  or  more  holes  accord- 
ing to  the  size  of  the  privy  desired,  and  each  hole  should  have  a  hinged  lid 
which  lifts  up  toward  the  back  of  the  room;  there  should  be  a  piece  of  wood 
nailed  across  the  back,  on  the  inside  of  the  room,  so  as  to  prevent  the  lids 
from  being  lifted  sufficientlv  to  fall  backward  and  so  as  to  make  them  fall 


296 


PRACTICAL   SANITATION. 


forward  of  their  own  accord  as  soon  as  the  person  rises.  In  this  box  there 
should  be  one  or  more  water-tight  tubs,  half  barrels,  pails,  or  galvanized  cans, 
corresponding  to  the  number  of  holes  in  the  seat.  This  receptacle  should  be 
high  enough  to  reach  nearly  to  the  seat,  or,  better  still,  so  as  to  fit  snugly 
against  the  seat,  in  order  to  protect  the  floor  against  soiling,  and  sufficiently 
deep  to  prevent  splashing  the  person  on  the  seat;   it  should  be  held  in  place 


Fig.  26. — A  sanitary  privy,  designed  to  prevent  soil  pollution.  Galvanized  pails  may  be 
used  instead  of  tubs.  The  door  should  be  kept  closed.  The  ventilators  should 
be  wire-screened  to  keep  out  flies.  The  seats  should  be  provided  with  hinged  lids. 
It  is  best  to  use  deeper   tubs   than    are   pictured   here.      (After   Stiles.) 


by  cleats  nailed  to  tlio  floor  in  such  a'  way  that  tlie  tul)  will  always  be  properly 
centered.     The  back  should  be  kept  closed,  as  shown  in  figure  27. 

15.  Tlic  Kiom  should  lie  water-tiglit  and  sliould  be  provided  in  front  with  a 
good,  tightly  fitting  door.  The  darker  this  room  can  be  made  the  fewer  flies 
will  enter.  The  roof  may  have  a  single  slant,  as  shown  in  figure  26,  or  a 
double  slant,  as  shown  in  figure  27,  but  while  the  double  slant  is  somewhat 
more  sightly,  the  single  slant  is  less  expensive  on  first  cost.     The  room  should 


PREVENTION    OF   SOIL   POLLUTION, 


297 


be  provided  with  two  or  three  wire-screened  ventilators,  as  near  the  roof  as 
possible. 

C.  Hie  ventilators  are  very  important  additions  to  the  privy,  as  they  permit 
a  free  circulation  of  air  and  thus  not  only  reduce  the  odor  but  make  the  out- 
house cooler.  These  ventilators  should  be  copper  wire  screened  in  order  to 
keep  out  flies  and  other  insects.     There  should  be  at  least  4    (better  5)    ven- 


l-H  IViiOsn 


Fig.  27. — A  sanitary  privy,  designed,  to  prevent  the  spread  of  disease.  If  a  privy  of 
this  type  were  built  on  every  farm  and  in  every  yard  in  villages,  and  if  this  privy 
■R-ere  used  by  all  persons,  typhoid  fever,  hookworm  disease,  and  various  other  mala- 
dies would  almost   or  entirely  disappear.      (After   Stiles.) 


tilatorSj  arranged  as  follows:  One  each  side  of  the  box;  one  each  side  of  the 
room  near  the  roof;  and  a  fifth  ventilator,  over  the  door,  in  front,  is  advisable. 
Latticework,  flowers,  and  vines. — At  best,  the  pri^-y  is  not  an  attractive 
addition  to  the  yard.  It  is  possible,  however,  to  reduce  its  unattractiveness 
by  surrounding  it  with  a  latticework  on  which  are  trained  vines  or  flowers. 
This  plan,  which  adds  but  little  to  the  expense,  renders  the  building  much 
less  unsightly  and  much  more  private. 


298 


PKACTICAL  SANITATION. 


Disinfectant. — It  is  only  in  comparatively  recent  years  that  the  privy  has 
been  tiioiight  worthy  of  scientific  studj',  and  not  unnaturally  there  is  some 
difference  of  opinion  at  present  as  to  the  best  plan  to  follow  in  regard  to 
disinfectants. 

(a)  Toj)  soil. — Some  persons  prefer  to  keep  a  box  or  a  barrel  of  top  soil, 
sand,  or  ashes  in  the  room  and  to  recommend  that  each  time  the  privy  is  used 


Fig.   28. — A  single-seated   sanitary   privy.     Front   view.      (After    Stiles.) 

tlic  excreta  be  covered  with  a  shovelful  of  the  dirt.  While  this  has  the 
advantage  of  simplicity,  it  has  the  disadvantage  of  favoring  carelessness,  as 
people  so  commonly  (in  fa^^t,  as  a  rule)  fail  to  cover  the  excreta;  further,  in 
order  to  have  the  best  results,  it  is  necessary  to  cover  the  discharges  very 
completely;  finally,  at  best,  our  knowledge  as  to  how  long  certain  germs  and 
spores  will  live  under  these  conditions  is  very  unsatisfactory. 

(h)   Lime. — Some  persons  prefer  to  have  a  box  of  lime  in  the  room  and 


PREVENTION    OP   SOIL   POLLUTION. 


299 


to  cover  the  excreta  with  this  material.  Against  this  system  there  is  the 
objection  that  tlie  lime  is  not  used  with  sufficient  frequency  or  liberality  to 
keep  insects  away,  as  is  sliown  by  the  fact  that  flies  carry  the  lime  to  the 
house  and  deposit  it  on  the  food. 

(c)  Water  and  oil. — A  very  cheap  and  simple  method  is  to  pour  into  the 
tub  about  2  or  3  inches  of  water;  this  plan  gives  the  excreta  a  chance  to  fer- 
mejit  and  liquefy  so  that  the  disease  germs  may  be  more  easily  destroj'ed.     If 


Fig.  29. — Rear  and  side  view  of  privy  shown  in  Fig.  28.      (After  Stiles.) 

this  plan  is  followed  a  cup  of  oil  (kerosene  will  answer)  should  be  poured  ou 
the  water  in  order  to  repel  insects. 

(d)  Cresol. — Some  persons  favor  the  use  of  a  5  per  cent  crude  carbolic 
acid  in  the  tub,  but  probably  the  compoimd  solution  of  cresol  (U.  S.  P.)  will 
be  found  equally  or  more  satisfactory  if  used  in  a  strength  of  1  part  of  this 
solution  to  19  parts  of  water. 

If  a  disinfectant  is  used  the  family  should  be  warned  to  keep  the  reserve 
supply  in  a  place  that  is  not  accessible  to  the  children,  otherwise  accidents 
may  result. 


300  PRACTICAL   SANITATION. 

Cleaning  the  receptacle. — The  frequency  of  cleaning  the  receptacle  depends 
upon  (a)  the  size  of  the  tub,  (b)  the  number  of  persons  using  the  privy,  and 
(c)  the  weather.-  In  general,  it  is  best  to  clean  it  about  once  a  week  in 
winter  and  twice  a  week  in  summer. 

An  excellent  plan  is  to  have  a  double  set  of  pails  or  tubs  for  each  privy. 
Suppose  the  outhouse  is  to  be  cleaned  every  Saturday :  Then  pail  No.  1  is 
taken  out  (say  January  1),  covered,  and  set  aside  until  the  following  Satur- 
day; pail  No.  2  is  placed  in  the  box  for  use;  on  January  8  pail  No.  1  is  emp- 
tied and  put  back  in  the  box  for  use  while  pail  No.  2  is  taken  out,  covered,  and 
set  aside  for  a  week  (namely,  until  January  15)  ;  and  so  on  throughout  the 
year.  The  object  of  this  plan  is  to  give  an  extra  long  time  for  the  germs  to 
be  killed  by  fermentation  or  by  the  action  of  the  disinfectant  before  the  pail 
is  emptied. 

Each  time  that  tlie  receptacle  is  emptied,  it  is  best  to  sprinkle  into  it  a 
layer  of  top  soil  about  a  quarter  to  half  an  inch  deep  before  putting  it  back 
into  the  box. 

Disposal  of  the  excreta. — For  the  present,  until  certain  very  thorough  in- 
vestigations are  made  in  regard  to  the  length  of  time  that  the  eggs  of  parasites 
and  the  spores  of  certain  other  germs  may  live  under  various  plans  (a)  to 
{d)  (see  pages  298-299),  it  is  undoubtedly  best  to  burn  or  boil  all 
excreta ;  wliere  this  is  not  feasible,  it  is  best  to  bury  all  human  discharges  at 
least  300  feet  away  and  down  hill  from  any  water  supply  (as  the  well, 
spring,  etc.). 

Many  farmers  insist  upon  using  the  fresh  night  soil  as  fertilizer.  In  warm 
clim.ates  this  is  attended  with  considerable  danger,  and  if  it  is  so  utilized,  it 
should  never  be  used  upon  any  field  upon  which  vegetables  are  grown  which 
are  eaten  uncooked;  further,  it  should  be  promptly  plowed  under. 

In  our  present  lack  of  knowledge  as  to  the  length  of  time  that  v-arious 
germs  (as  spores  of  the  ameba.  which  produce  dysentery,  various  eggs,  etc.) 
may  live,  the  use  of  fresh,  unboiled  night  soil  as  a  fertilizer  is  false  economy 
lohich  may  result  in  loss  of  human  life.  This  is  especially  true  in  loarm 
climates. 

Directions  for  Building  a  Sanitary  Privy. 

In  order  to  put  the  construction  of  a  sanitary  privy  for  the  home  within 
the  carpentering  abilities  of  boys,  a  practical  carpenter  has  been  requested 
to  construct  models  to  conform  to  the  general  ideas  expressed  in  this  article, 
and  to  furnish  estimates  of  the  amount  of  lumber,  hardware,  and  wire  screen- 
ing required.  The  carpenter  was  requested  to  hold  constantly  in  mind  two 
points,  namely,  (1)  economy  and  (2)  simplicity  of  construction.  It  is  be- 
lieved that  any  14-year-old  schoolboy  of  average  intelligence  and  mechanical 
ingenuity  can,  by  following  these  plans,  build  a  sanitary  privy  for  his  home 
at  an  expense  for  building  materials,  exclusive  of  receptacle,  of  $5  to  $10, 
according  to  locality.  It  is  further  believed  that  the  plans  submitted  cover 
the  essentia]  points  to  be  considered.  They  can  be  elaborated  to  suit  the  in- 
dividual taste  of  persons  who  prefer  a  more  elegant  and  more  expensive  struc- 
ture. For  instance,  the  roof  can  have  a  double  (fig.  27)  instead  of  a  single 
slant,  and  can  be  shingled;  the  sides,  front,  and  back  can  be  clapboarded  or 


PREVENTION    OP    SOIL   POLLUTION.  301 

they  can  be  shingled.  Instead  of  one  seat  (figs.  28,  29)  or  six  seats  (figs.  30, 
31),  there  may  be  two,  three,  four,  or  five  seats,  etc..  according  to  necessity. 

A  Single-seated  Privy  for  the  Home.- — Nearly  all  privies  for  the  home 
have  seats  for  two  persons  ( fig.  20 ) ,  but  a  single  privy  can  be  made  more 
economically. 

Frameivork. — The  lumber  required  for  the  framework  of  the  outhouse  shown 
in  figure  28  is  as  follows : 

A.  Two  pieces  of  lumber  (scantling)   4  feet  long  and  6  inches  square  at  ends. 

B.  One  piece  of  lumber  (scantling)  3  feet  10  inches  long;  4  inches  square 
at  ends. 

C.  Two  pieces  of  lumber  (scantling)  3  feet  4  inches  long;  4  inches  square 
at  ends. 

D.  Two  pieces  of  lumber  (scantling)  7  feet  9  inches  long;  2  by  4  inches 
at  ends. 

E.  Two  pieces  of  lumber  (scantling)  6  feet  7  inches  long;  2  by  4  inches 
at  ends. 

F.  Two  pieces  of  lumber  (scantling)  6  feet  3  inches  long;  2  by  4  inches 
at  ends. 

G.  Two  pieces  of  lumber   (scantling)   5  feet  long;  2  by  4  inches  at  ends. 

H.  One  piece  of  lumber  (scantling)  3  feet  10  inches  long;  2  by  4  inches 
at  ends. 

I.  Two  pieces  of  lumber  (scantling)  3  feet  4  inches  long;  2  by  4  inches 
at  ends. 

J.  Two  pieces  of  lumber  (scantling)   3  inches  long;  2  by  4  inches  at  ends. 

K.  Two  pieces  of  lumber  (scantling)   4  feet  7  inches  long;  6  inches  wide  by 

1  inch  thick.     The  ends  of  K  should  be  trimmed  after  being  nailed  in  place. 

L.  Two  pieces  of  lumber  (scantling)  4  feet  long,  6  inches  wide,  and  1  inch 
thick. 

First  lay  down  the  sills  marked  A  and  join  them  with  the  joist  marked  B; 
then  nail  in  position  the  two  joists  marked  C,  with  their  ends  3  inches  from 
the  outer  edge  of  A;  raise  the  corner  posts  (D  and  F),  spiking  them  at  bottom 
to  A  and  C,  and  joining  them  with  L,  Ij,  G,  and  K;  raise  door  posts  E, 
fastening  them  at  J,  and  then  spike  Ij  in  position;  H  is  fastened  to  K. 

Kic/e.s. — Each  side  requires  four  boards  (a)  12  inches  wide  by  1  inch  thick 
and  8  feet  6  inches  long;  these  are  nailed  to  K,  L,  and  A.  Tlie  corner  boards 
must  be  notched  at  G,  allowing  them  to  pass  to  bottom  of  roof;  next  draw  a 
slant  from  front  to  back  at  G-G,  on  the  outside  of  the  boards,  and  saw  the 
four  side  boards  to  correspond  with  this  slant. 

Back. — The  back  requires  two  boards  (b)  12  inches  wide  by  1  inch  thick 
and  6  feet  11  inches  long,  and  two  boards  (c)  12  inches  wide  by  1  inch  thick 
and  6  feet  5  inches  long.  The  two  longest  boards  (b)  are  nailed  next  to  the 
sides;  the  shorter  boards  (c)  are  sawed  in  two  so  that  one  piece  (ci)  meas- 
ures 4  feet  6  inches,  the  other  (c2)  1  foot  11  inches;  the  longer  pprtion  (ci)  is 
nailed  in  position  above  the  seat;  the  shorter  portion  (c2)  is  later  utilized  in 
making  the  back  door. 

Floor. — The  floor  requires  four  boards  (d)  Avhich  (when  cut  to  fit)  measure 
1  inch  thick,  12  inches  wide,  and  3  feet  10  inches  long. 


302  PRACTICAL   SANITATION. 

Front. — The  front  boards  may  next  be  nailed  on.  The  front  requires  (aside 
from  tlie  door)  two  boards  (e)   which   (when  cut  to  fit)   measure  1  inch  thick, 

9  inelies  wide,  and  8  feet  5  inches  long;  these  are  nailed  next  to  the  sides. 
Roof. — The    roof    may    now    be    finished.     This    requires    five    boards     (f) 

measuring  (when  cut  to  fit)  1  inch  thick,  12  inches  wide,  and  6  feet  long. 
They  are  so  placed  that  thej^  extend  8  inches  beyond  the  front.  The  joints 
(cracks)  are  to  be  broken  (covered)  by  laths  one-half  inch  thick,  3  inches 
broad,  and  6  feet  long. 

Box. — Tlie  front  of  the  box  requires  two  boards,   1   inch  thick  and  3   feet 

10  inches  long.  One  of  these  (g)  may  measure  12  inches  wide,  the  other  (h) 
5  inches  wide.  These  are  nailed  in  place,  so  that  the  back  of  the  boards  is 
18  inches  from  the  inside  of  the  backboards.  The  seat  of  the  box  requires 
two  boards,  1  in^h  thick,  3  feet  10  inches  long;  one  of  these  (i)  may  measure 
12  inches  wide,  the  other  (j)  7  inches  wide.  One  must  be  jogged  (cut  out) 
to  fit  around  the  back  corner  posts  (F).  An  oblong  hole,  10  inches  long  and 
7J  inclies  wide,  is  cut  in  the  seat.  The  edge  should  be  smoothly  rounded  or 
beveled.  An  extra  (removable)  seat  for  children  may  be  made  by  cutting  a 
toard  1  inch  thick,  15  inches  wide,  and  20  inches  long;  in  this  seat  a  hole  is 
cut,  measuring  7  inches  long  by  6  inches  wide;  the  front  margin  of  this  hole 
should  be  about  3  inches  from  the  front  edge  of  the  board;  to  prevent  warping, 
a  cross  cleat  is  nailed  on  top  near  or  at  each  end  of  the  board. 

A  cover  (k)  to  the  seat  should  measure  1  inch  thick  by  15  inches  wide  by 
20  inches  long;  it  is  cleated  on  top  near  the  ends,  to  prevent  warping;  it  is 
hinged  in  back  to  a  strip  1  inch  thick,  3  inches  wide,  and  20  inelies  long, 
which  is  fastened  to  the  seat.  Cleats  (m)  may  also  be  nailed  on  the  seat  at 
the  sides  of  the  cover.  On  the  inside  of  the  backboard,  12  inches  above  the 
seat,  there  should  be  nailed  a  block  ( 1 ) ,  2  inches  thick,  6  inches  long,  extend- 
ing forward  3 J  inches;  this  is  intended  to  prevent  the  cover  from  falling  back- 
ward and  to  make  it  to  fall  down  over  the  hole  when  the  occupant  rises. 

On  the  floor  of  the  box  (underneath  the  seat)  two  or  three  cleats  (n)  are 
nailed  in  such  a  position  that  they  will  always  center  the  tub;  the  position 
of  these  cleats  depends  upon  the  size  of  the  tub. 

Bade  door. — In  making  the  back  of  the  privy  the  two  center  boards  (c) 
were  sawed  at  the  height  of  the  bottom  of  the  seat.  The  small  portions  (c2) 
sawed  off  (23  inches  long)  are  cleated  (o)  together  so  as  to  form  a  back  door 
which  is  hinged  above;  a  bolt  or  a  button  is  arranged  to  keep  the  door 
closed. 

Front  door. — The  front  door  is  made  by  cleating  (p)  together  three  boards 
(q)  1  in'-'h  thick,  10  inches  wide,  and  (when  finished)  6  feet  7  inches  long; 
it  is  best  to  use  three  cross  cleats  (p)  (1  inch  thick,  6  inches  wide,  30  inches 
long) ,  which  are  placed  on  the  inside.  The  door  is  hung  with  two  hinges 
(6-inch  "strap"  hinges  will  do),  which  are  placed  on  the  right  as  one  faces 
the  privy,  so  that  the  door  opens  from  the  left.  The  door  should  close  with 
a  coil  spring  (cost  about  10  cents)  or  with  a  rope  and  weight,  and  may  fasten 
on  the  inside  with  a  catch  or  a  cord.  Under  the  door  a  crosspiece  (r)  I  inch 
thick,  4  inches  wide,  30  inclies  long  (when  finished)  may  be  nailed  to  the 
joist.  Stops  (s)  may  be  placed  inside  the  door  as  shown  in  figure  5.  These 
should  be  1  inch  thick,  3  inches  wide,  and  6  feet  6  inches  long,  and  should  be 


PREVENTION    OF    SOIL   POLLUTION.  303 

jogged  (cut  out)  (t)  to  fit  the  cross  cleats  (p)  on  the  door.  Close  over  the 
top  of  the  door  place  a  strip  (v)  1  inch  thick,  2  inches  wide,  30  inches  long, 
nailed  to  I.  A  corresponding  piece  (v)  is  placed  higher  up  directly  under  the 
roof,  nailed  to  G.     A  strap  or  door  pull  is  fastened  to  the  outside  of  the  door. 

Ventilators. — There  should  be  five  ventilators  (w).  One  is  placed  at  each 
side  of  the  box,  directlj^  under  the  seat;  it  measures  6  to  8  inches  square. 
Another  (12  inches  square)  is  placed  near  the  top  on  each  side  of  the  privy. 
A  fifth  (30  inr-hes  long,  8^  inches  wide)  is  placed  over  the  door,  between  G 
and  Ij.  The  ventilators  are  made  of  15-mesh  copper  wire,  which  is  first  tacked 
in  place  and  then  protected  at  the  edge  with  the  same  kind  of  lath  that  is 
used  on  the  cracks  and  joints. 

Lath. — Outside  cracks  (joints),  are  covered  with  lath  one-half  inch  thick 
by  3  inches  wide. 

Receptacle. — For  a  receptacle,  saw  a  water-tight  barrel  to  fit  snugly  under 
the  seat;  or  purchase  a  can  or  tub,  as  deep  (17  inches)  as  the  distance  from 
the  under  surface  of  the  seat  to  the  floor.  If  it  is  not  possible  to  obtain  a 
tub,  barrel,  or  can  of  the  desired  size,  the  receptacle  used  should  be  elevated 
from  the  floor  by  blocks  or  boards  so  that  it  fits  snugly  under  the  seat. 
A  galvanized  can  measuring  16  inches  deep  and  16  inches  in  diameter  can  be 
purchased  for  about  $1,  or  even  less.  An  empty  candy  bucket  can  be  pur- 
chased for  about  10  cents. 

Order  for  material. — The  carpenter  has  made  out  the  following  order  for 
lumber  (pine.  No.  1  grade)  and  hardware  to  be  used  in  building  a  privy  such 
as  is  shown  in  figure  28 : 

1  piece  scantling,  6  by  6  inches  by  8  feet  long,  24  square  feet. 

1  piece  scantling,  4  by  4  inches  by  12  feet  long,  16  square  feet. 

5  pieces  scantling,  2  by  4  inches  by  16  feet  long,  54  square  feet. 
3  pieces  board,  1  by  6  inches  by  16  feet  long,  24  square  feet. 

2  pieces  board,  1  by  9  inches  by  9  feet  long,  14  square  feet. 

3  pieces  board,  1  by  10  inches  by  7  feet  long,  18  square  feet. 
15  pieces  board,  1  by  12  inches  by  12  feet  long,  180  square  feet. 
12  pieces  board,  i  by  3  inches  by  16  feet  long,  48  square  feet. 

2  pounds  of  20-penny  spikes. 

6  pounds  of  10-penny  nails. 
2  pounds  of  6-penny  nails. 

7  feet  screen,  15-mesh,  copper,  12  inches  wide. 

4  hinges,  6-inch  "strap,"  for  front  and  back  doors. 
2  hinges,  6-inch  "T,"  or  3-inch  "butts,"  for  cover. 

1  coil  spring  for  front  door. 

According  to  the  carpenter's  estimate,  these  materials  will  cost  from  $5  to 
$10,  according  to  locality. 

There  is  some  variation  in  the  size  of  lumber,  as  the  pieces  are  not  abso- 
lutely uniform.  The  sizes  given  in  the  lumber  order  represent  the  standard 
sizes  which  should  be  ordered,  but  the  purchaser  need  not  expect  to  find  that 
the  pieces  delivered  correspond  with  mathematical  exactness  to  the  sizes  called 
for.  On  this  account  the  pieces  must  be  measured  and  cut  to  measure  as  they 
are  put  together. 


304 


305 


306  PEACTICAL   SANITATION. 

Estimate  of  Material  for  School  Privy. 

Tlie  following  estimate  of  building  materials  has  been  made,  by  a  carpenter, 
for  the  construction  of  a  six-seated  school  privy  such  as  is  shown  in  figure  30. 
The  estimated  cost  of  these  materials  is  $25  to  $50,  according  to  localitj^;  this 
does  not  include  the  pails,  which  ought  not  to  cost  over  $1  a  piece: 

3  pieces  scantling,  6  by  6  inches  by  20  feet,  ISO  square  feet. 

1   piece  scantling,  6  by  6  inches  by  8  feet,  24  sqviare  feet. 

Scantling,  2  by  4  inches,  165  square  feet. 

Boards,  1  by  12  inches,  600  square  feet. 

Boards,  1  by  10  inches,  185  square  feet. 

Boards,  1  by  8  inches,  100  square  feet. 

Boards,  1  by  6  inches,  80  square  feet. 

Boards,  i  by  3  inches,  100  square  feet. 

Flooring,  80  square  feet. 

40  feet  15-mesh  copper  wire  screen,  12  inches  wide. 

12  pairs  of  hinges,  6-inch  "strap." 

6  pairs  of  hinges,  6-inch  "T." 

3  pounds  of  20-penny  spikes. 
15  pounds  of  10-penny  nails. 

8  pounds  of  6-penny  nails. 

6  coil  springs  for  front  doors. 

6  knobs  or  latches. 

A  Compulsory  Sanitary  Privy  Law. — Privy  License. 

A  compulsory  sanitary  privy  law  or  ordinance  should  exist  and  be  strictly 
enforced  in  all  localities  in  which  connection  Avith  a  sewer  system  is  not 
enforced. 

Since,  from  a  sanitary  point  of  view,  the  privy  is  a  public  structure,  in 
that  it  influences  public  health,  it  seems  wisest  to  have  city  and  town  ordi- 
nances which  provide  for  a  licensing  of  all  privies,  the  license  being  fixed  at 
a  sum  which  will  enable  the  city  or  town  to  provide  the  receptacle  (tub,  pail, 
etc.),  the  disinfectant,  and  the  service  for  cleaning.  The  expense  involved  will 
vary  according  to  local  conditions,  such  as  cost  of  labor  and  density  of  popula- 
tion. If  the  "chain  gang"  can  be  utilized  for  cleaning,  the  expense  for  labor 
is  reduced. 

The  importance  of  taking  the  responsibility  for  the  care  of  the  privy  out  of 
the  hands  of  the  family  is  evident  when  one  considers  that  one  careless  family 
in  ten  or  in  a  hundred  might  be  a  menace  to  all.  Quite  generally  the  removal 
of  garbage  and  of  ashes  is  recognized  as  a  function  of  the  city  or  town  in  all 
better  organized  communities,  and  the  idea  is  constantly  spreading  that  this 
service  should  extend  to  a  removal  of  the  night  soil  also. 

In  correspondence  with  certain  cotton  mills,  estimates  for  privy  cleaning 
(oive  a  week)  vary  from  about  20  to  25  cents  per  privy  per  month.  A  privy 
tax  of  $3.50  to  .$5  per  privy  per  year  ought  to  give  satisfactory  service,  in- 
cluding receptacle,  but  the  exact  amount  of  the  tax  must  be  determined  by 
experience  in  each  locality. 


TREVENTION    OF    SOIL   POLLUTION.  307 

It  is  probably  the  exception  that  an  economical  public  privy-cleaning  serv- 
ice can  be  carried  out  in  the  open  country,  on  account  of  the  distances  between 
the  houses.  To  meet  the  difficulties  involved,  several  suggestions  may  be  con- 
sidered, according  to  conditions:  A  county  privy  tax  can  be  levied,  the  county 
can  furnish  the  pail  and  the  disinfectant,  and  (1)  one  member  of  each  family 
or  of  several  neigiiboring  families  hired  to  clean  the  privy  regularly;  or  (2) 
the  landlord  can  be  held  responsible  for  the  cleaning  of  all  privies  of  his 
tenants,  receiving  from  the  county  a  certain  sum  for  the  service;  or  (3) 
"trusties"  from  prisons  might  possibly  be  utilized  in  some  districts  not  too 
sparsely  settled;  or  (4)  a  portion  of  the  county  privy  tax  might  perhaps  be 
apportioned  by  school  districts  and  be  distributed  as  prizes  among  the  school 
boys  who  keep  their  family  privy  in  best  conditions;  or  (5)  each  head  of 
fan:ily  might  be  held  responsible  for  any  soil  pollution  that  may  occur  on  his 
premises  and  be  fined  therefor. 

Undoubtedly  the  problem  of  the  privy  cleaning  in  the  open  country  is  much 
more  difficult  than  in  cities,  villages,  and  towns,  and  in  the  last  instance 
involves  a  general  education  of  the  rising  generation  of  school  children,  more 
particularly  of  the  girls  (the  future  housekeepers),  in  respect  to  the  dangers 
of  soil  pollution. 


CHAPTER  XXXIII. 
SEWAGE  DISPOSAL. 

Water-closets. — Where  water  under  pressure  is  available,  water- 
closets  are,  if  properly  installed,  the  most  convenient  way  of  dis- 
posing of  human  excreta.  This  sewage  is  then  conducted  through 
drains  of  vitrified  tile  of  proper  size,  away  from  the  house.  In 
towns  and  cities  having  a  municipal  sewerage  system  within  reach, 
every  householder  should  be  required  to  connect  his  premises  with 
it.  The  subject  of  municipal  disposal  of  sewage  is  beyond  the  scope 
of  this  handbook,  further  than  to  say  that  there  are  a  number  of 
ways  in  which  sewage  may  be  made  harmless,  and  in  some  of  which 
it  is  made  useful.  Every  municipality  installing  a  sewer  system 
has  its  own  particular  problems  to  meet,  owing  to  the  varying 
topography  and  geology  of  the  country,  the  density  of  the  popula- 
tion served,  the  probable  growth  of  the  town,  the  amount  of  sewage 
to  be  handled,  the  presence  or  absence  of  packing-house  and  other 
manufacturing  wastes,  and  so  on.  One  method  is  here  mentioned 
to  be  condemned — the  discharge  of  raw  sewage  either  into  streams 
or  tidewater,  since  it  invariably  becomes  a  source  of  danger  to  com- 
munities to  which  the  water  carries  it. 

Sewer  Construction. — Any  municipality  about  to.  build  a  sewer 
system  should  consult  with  the  State  Board  of  Health  or  State  Sani- 
tary Engineer  as  to  the  problems  involved,  and  for  the  actual  con- 
struction should  employ  the  very  best  sanitary  engineer  they  can 
afford.  A  few  hundred  dollars  more  in  the  M^ay  of  a  fee  will  fre- 
quently save  thousands  in  construction,  or  will  make  the  difference 
between  an  easily  operated,  satisfactory  system  and  one  the  reverse 
in  every  way.  If  the  detailed  plans  are  submitted  to  the  State 
Sanitary  Engineer  before  acceptance,  it  will  prevent  any  criticism 
afterward  in  case  there  is  trouble. 

Where  there  is  no  municipal  system  of  sewers,  the  householder  is 
compelled  to  dispose  of  this  waste  himself.  This  may  be  done  in 
a  number  of  ways,  of  which  two  very  satisfactory  ones  will  be  here 
noticed : 

308 


SEWAGE   DISPOSAL. 


309 


1.  By  leaching  cesspools.  This  method  is  mentioned  only  to  be 
condemned.  In  it  the  cesspool  is  not  built  tight,  but  the  contents 
are  expected  to  leach  into  the  ground  or  to  find  their  way  into  rock 
fissures.  It  is  a  highly  effective  way  of  contaminating  water  sup- 
plies even  at  a  considerable  distance. 

2.  By  tight  cesspools.  These  are  underground  tanks,  built  like 
a  cistern,  and  cemented  in  the  same  way.  They  require  to  have  the 
contents  pumped  or  bailed  out  at  intervals,  varying  with  the  duty 
performed  by  them.  They  are  much  more  expensive  to  install  than 
the  next  form,  but  are  sometimes  the  only  method  available.  The 
expense  of  emptying  is  also  a  disadvantage.  If  emptied,  the  con- 
tents must  be  put  on  a  field  and  plowed  under,  the  field  then  being 
planted  to  some  crop  which  will  not  be  contaminated. 

3.  The  Septic  Tank.  This  consists  of  two  underground  com- 
municating compartments  so  arranged  that  the  sewage  which  has 


m\%^i\^^A^%^^#^^ 


Fig.  32. — Cement  Septic  Tank.  AAA,  ground  level;  BB,  baffles;  CC,  septic  chambers; 
MM,  manholes;  /,  inlet;  O,  outlet;.  Dotted  line  indicates  surface  of  fluid.  (Adapted 
from   Steiner.) 


undergone  fermentation  and  partial  destruction  of  its  organic  con- 
tents by  the  anaerobic  organisms  contained  in  it,  flows  out  through 
porous  tiles  just  deep  enough  not  to  be  reached  by  frost,  and  the 
remainder  of  the  material  is  oxidized  and  destroyed  by  the  nitrify- 
ing bacteria  of  the  soil.  In  localities  where  the  soil  is  frozen  to 
considerable  depths,  this  method  will  hardly  be  found  satisfactory, 
since  the  frost  line  will  probably  be  deeper  than  the  nitrifying 
bacteria  are  able  to  penetrate.  In  climates  which  will  admit  of  it, 
the  tile  drain  should  run  only  10  .or  12  inches  below  the  surface, 
with  a  slope  of  about  1  inch  to  20  feet. 

The  arrangement  of  the  chambers  is  shown  in  the  cut,  Figiire  32. 
The  dimensions  inside  are  8  feet  in  length  by  4  in  width  and  3  in 
depth.  The  manholes  are  for  the  purpose  of  cleaning  out  the 
sludge,  which  is  necessary  only  about  once  in  two  years.  The 
material  should  be  concrete  of  good  quality,  4  inches  thick. 


310  PRACTICAL   SANITATION. 

The  inlet  is  by  an  elbow  so  placed  that  the  mouth  rests  at  the 
water  level,  or  a  trifle  below,  forming  a  trap.  The  two  baffles 
shown  in  the  cross  section  prevent  a  too  rapid  flow  into  the  second 
chamber.  The  tank  must  be  kept  dark,  and  the  influx  and  efflux 
of  the  sewage  so  arranged  that  the  liquid  is  disturbed  as  little  as 
possible,  since  the  anaerobic  organisms  work  better  in  quiet. 

The  inlet  pipe  is  of  vitrified  pipe,  cemented  at  the  joints,  laid 
with  as  little  fall  as  will  insure  freedom  from  clogging. 

The  outlet  tile  is  also  laid  with  little  fall,  as  above  stated,  in 
order  that  the  seepage  may  be  constant  along  its  whole  length  and 
not  wet  the  surface  of  the  ground  at  any  one  place.  In  fairly 
porous  soil  a  drain  of  50  feet  in  length  will  be  sufficient.  The 
effluent  can  also  be  discharged  into  a  field  drain  without  danger,  in 
the  country.  The  cost  of  a  septic  tank  of  the  capacity  named  is 
about  $250.00  to  $300.00,  and  the  materials  are  to  be  had  anywhere. 
Metal  septic  tanks  are  also  to  be  had,  which  answer  the  same  pur- 
pose. 

Either  of  the  methods  2  and  3  will  give  good  results  if  properly 
built  and  cared  for.  They  must  not  be  allowed  to  run  over  on  the 
surface  of  the  ground  nor  to  leak  into  the  soil,  and  if  so  handled, 
present  probably  the  best  ways  of  caring  for  sewage  in  towns  not 
provided  with  municipal  sewage. 

Municipal  Purification  Plants. — Several  methods  of  disposal  of 
sewage  are  in  use.  The  simplest,  but  on  all  accounts  least  desirable, 
is  to  turn  the  raw  sewage  into  the  nearest  stream  or  body  of  water. 
Even  the  ocean  is  not  desirable  for  this  purpose,  as  the  tides  and 
currents  sweep  the  filth  back  to  the  land  and  pollute  the  shore  for 
miles  distant,  h-till  very  large  cities  are  compelled  to  employ  this 
means  because  no  other  method  has  as  yet  been  devised  applicable  to 
them. 

Irrigation. — In  the  arid  and  semi-arid  portions  of  the  Southwest 
of  the  Ihiited  States,  where  water  is  at  a  premium  and  where  a 
sandy  soil  and  dry  atmosphere  tend  to  simplify  the  problem,  broad 
irrigation  of  such  crops  as  alfalfa  with  sewage  is  employed  with 
satisfaction.  It  has  the  advantage  that  what  would  otherwise  be  a 
source  of  expense  becomes  an  asset,  and  the  disadvantage  that  a 
large  area  is  needed  for  the  farm  and  only  under  special  conditions 
is  it  successful.  It  is  possible,  however,  to  use  the  outfall  from  the 
septic  tanks  to  be  described  in  the  next  paragraph  for  this  purpose 
wherever  the  topography  of  the  country  will  permit,  and  so  to  se- 


SEWAGE   DISPOSAL.  311 

cure  for  the  crops  a  liciuid  high  in  aninionia  and  mineral  fertilizer. 
At  the  same  time  an  avenue  is  found  for  the  disposal  of  at  least  a 
part  of  what  is  at  hest  a  disagreeable  waste. 

Septic  or  Imhoff  Tanks. — For  municipal  plants  much  larger 
tanks  on  the  general  principle  of  the  ones  described  for  household 
use,  and  grouped  in  units  so  that  no  one  unit  will  be  working  more 
than  six  hours  of  the  day,  are  in  use  by  many  cities.  They  need  not 
be  covered  except  in  very  cold  climates  as  the  fermenting  sewage 
furnishes  enough  heat  to  prevent  freezing,  and  the  scum  on  the  top 
cuts  down  the  light  sufficiently  for  the  luxuriant  growth  of  the 
anaerobic  bacteria.  The  hea;vy  sludge  settles  to  the  bottom  and  by 
the  digestive  action  of  the  putrefactive  bacteria  gradually  passes 
into  solution  to  be  thrown  off  with  the  liquid  portion.  These  cham- 
bers are  so  planned  as  to  discharge  automatically  when  full,  the 
effluent  being  sprayed  either  into  the  air  through  a  set  of  sprinklers 
or  forced  into  the  contact  beds  through  inverted  sprinklers  with- 
out becoming  visible.  These  contact  beds  are  filters  of  broken 
stone,  gravel  or  sand,  so  arranged  as  to  provide  a  maximum  of  ac- 
cess of  air  to  the  depths  of  the  filter,  in  order  to  favor  the  growth 
of  aerobic  organisms  which  complete  the  work  of  destruction  of  the 
sewage.  The  outfall  from  the  filter  beds  is  still  very  rich  in  organic 
matter  and  is  alive  with  bacteria,  but  it  is  now  relatively  harmless 
because  no  pathogenic  organisms  are  capable  of  withstanding  the 
treatment  described  above.  Both  the  tanks  and  the  effluent  are 
somewhat  offensive  to  the  senses  owing  to  the  presence  of  the  gases 
of  deeompcsiticn.  At  times  of  flood  the  sludge  in  the  tanks  is  al- 
lowed to  flow  into  any  convenient  stream,  the  flood  water  so  diluting 
it  as  to  render  it  harmless  and  inoffensive. 

Incineration. — Incinerators  are  now  built  which  are  very  satis- 
factory so  far  as  sanitary  results  are  concerned,  but  most  of  them 
are  slightly  disagreeable  on  account  of  odors  during  the  process  of 
burning  up  the  excrement.  They  are  made  in  all  sizes,  from  one 
seat  to  a  dozen  or  more,  and  are  a  very  good  solution  of  the  problem 
of  public  closets  in  small  towns. 


CHAPTER  XXXIV. 

DISPOSAL  OF  GARBAGE. 

Garbage  Nuisances. — Almost  the  most  annoying  problems  which 
the  health  officer  has  to  deal  with  in  small  municipalities  are 
those  connected  with  the  disposal  of  garbage.  People  will 
throw  slops,  dishwater,  kitchen  refuse,  tin  cans  or  what  not 
into  the  alleys,  their  own  or  their  neighbors  back  yards.  Small, 
animals  are  allowed  to  remain  unburied  or  unburned,  and  the  health 
officer  is  called  in  to  settle  the  difficulty  when  the  neighbors  com- 
plain of  the  nuisance. 

Garbage  Disposal.— There  are  three  practical  ways  to  dispose 
of  garbage :  to  bury  it,  to  burn  it,  and  to  have  it  hauled  away.  In 
small  places  where  the  building  lots  are  large,  burial  is  a  very  good 
way.  The  pits  are  dug  just  big  enough  to  hold  a  pail  of  garbage, 
and  are  at  once  filled  in  with  3  or  4  inches  of  earth  over  the  top, 
and  a  new  site  is  taken  for  each  successive  pail. 

If  coal  or  wood  is  used  for  fuel,  the  liquids  are  drained  from  the 
garbage,  and  the  solid  residue  placed  in  the  ash-pan  when  the  fire 
is  first  lighted.  In  half  an  hour  it  will  be  sufficientlj'-  dry  to  burn, 
and  may  be  placed  on  the  fire.  There  then  remains  nothing  but 
ashes  to  be  disposed  of.  Tin  cans  should  always  be  burned  out 
to  destroy  the  organic  matter  which  draws  flies,  and  to  melt  them 
apart,  in  order  that  they  may  not  collect  water  where  mosquitoes 
may  breed  when  thrown  on  the  dump. 

Domestic  Incinerators. — Small  incinerators  are  now  built  to 
stand  in  the  basement  or  kitchen  and  by  the  combustion  of  the  gar- 
bage aided  by  a  small  amount  of  coal  or  wood,  to  furnish  hot  water 
foi-  tlie  house. 

Dumping, — In  places  where  gas  is  used  for  cooldng,  it  is  probable 
that  the  building  lots  will  be  too  small  to  bury  wastes  and  coal 
or  wood  stoves  will  not  be  available  to  burn  them.  During  cold 
weather  heating  stoves  or  furnaces  may  be  utilized  as  incinerators, 
but  during  hot  weather  it  will  be  necessary  to  have  all  wastes  hauled 
to  a  distance  from  town  and  dumped.     This  is  properly  a  function 

312 


DISPOSAL   OF    GARBAGE.  313 

of  the  municipality,  but  will  ordinarily  be  paid  for  privately  for  a 
long  time  before  the  municipality  can  be  induced  to  take  it  up. 
These  dumps  will  become  a  nuisance  if  located  near  roads  or  dwell- 
ings, and  it  is  best  to  utilize  the  waste  materials  for  filling  up  an 
unsightly  ravine  or  sinkhole,  if  possible.  If  this  cannot  be  done,  a 
plan  should  be  devised  for  burning  up  organic  matter  at  intervals, 
with  the  assistance  of  crude  oil  or  other  combustible,  and  utilizing 
a  time  of  dry  weather  for  it.  Otherwise  flies  may  become  a  great 
nuisance  near  the  dump.  The  practice  of  feeding  raw  garbage  to 
hogs  is  dangerous  and  should  not  be  allowed. 

There  are  two  great  cardinal  principles  in  the  handling  of  gar- 
bage at  all  stages;  the  solid  and  liquid  portions  must  be  kept 
separate,  and  flies  must  be  kept  out.  The  best  way  of  doing  the 
first  is  by  the  use  of  two  covered  cans,  one  having  a  strainer,  and  of 
the  second,  is  to  see  that  the  covers  are  always  in  place.  Metallic 
cans  should  be  used  but  are  not  always  practical  on  account  of  the 
expense.  Large  lard-cans  make  good  garbage  cans,  and  cost  next  to 
nothing. 

All  ordinances  of  this  kind  are  difficult  of  enforcement  because 
the  laity  cannot  be  made  to  see  their  importance.  The  only  remedy 
for  this  is  a  long  continued  campaign  of  education,  with  prosecution 
in  flagrant  cases. 

Municipal  Plants. — These  are  of  two  kinds,  incinerators  or  de- 
structors, and  redUrCtioji  plants.  The  first  of  these  is  simply  what 
the  name  implies,  a  plant  consisting  of  one  or  more  furnaces  de- 
signed to  burn  the  waste  and  garbage  of  a  town  with  a  minimum  of 
other  fuel.  It  is  possible  to  use  this  method  in  a  city  of  any  size 
which  can  afford  a  plant  at  all,  but  it  is  wasteful  although  from  a 
sanitary  point  of  view  it  is  beyond  criticism.  From  an  economic 
point  of  view  this  method  is  much  inferior  to  the  reduction  method. 
In  this  latter  plan,  all  waste  and  garbage  are  taken  to  the  plant, 
the  different  kinds  being  kept  separate  as  far  as  possible,  and  are 
then  sorted.  All  junk  is  thrown  into  bins  to  be  sold  later  as  such. 
The  dry  useless  waste  is  sent  to  the  furnaces,  and  kitchen  garbage, 
dead  animals  and  so  on  are  put  into  large  tanks  to  which  steam  un- 
der pressure  is  admitted.  This  after  cooking  at  a  high  temperature 
is  drawn  off*  into  filter  presses  and  the  grease  and  water  pressed  out. 
The  grease  is  then  sold  to  manufacturers  of  cheap  soaps  and  the 
solid  residue  is  utilized  as  a  fertilizer.  Many  cities  thus  make  their 
garbage  pay  a  small  profit  over  the  cost  of  caring  for  it. 


314  PRACTICAL  SANITATION. 

Manure. — The  proper  care  of  stable  manure  in  order  that  it  may 
not  become  a  breeding  place  for  flies  is  best  attained  by  requiring 
it  to  be  kept  in  a  dark  place  and  moved  at  least  once  a  week.  Ce- 
ment bins  are  best  for  this  purpose,  as  they  retain  the  liquid  con- 
stituents in  the  manure,  instead  of  allowing  them  to  drain  off  and 
become  a  nuisance.  The  use  of  borax  for  preventing  the  breeding 
of  flies  will  be  found  described  in  the  chapter  on  that  subject. 


CHAPTER  XXXV. 

SANITARY  FOOD  INSPECTION. 

Laws. — Laws  having  to  do  with  the  preparation  and  sale  of  food 
products  are  of  two  kinds — Pure  Food  Laws  and  Sanitary  Food 
Laws. '.  Laws  of  the  first  sort  have  to  do  with  the  prevention  of 
adulterations,  and  the  maintenance  of  certain  standards  of  quality 
as  determined  by  chemical  analysis,  while  statutes  of  the  second 
kind,  aim  at  the  production  of  foods  and  their  preservation  in  ap- 
proved ways. 

Pure  food  laws  will  not  be  considered  further  than  to  say  that  all 
of  the  states  have  statutes  concerning  the  standards  of  food  and 
drugs  which  may  be  sold  within  their  borders,  while  the  United 
States  act  covers  articles  sold  in  inter-state  commerce.  But  the 
standards  set  up  by  these  different  laws  vary  so  much  that  it  would 
be  unprofitable,  outside  of  a  monograph  on  the  subject,  to  attempt 
to  take  them  up  in  detail.  One  thing  most  of  them  have  in  com- 
mon, and  in  common  also  with  sanitary  food  laws — they  brand  as 
adulterated  foods  containing  dirt  of  any  description.  The  health 
official  who  desires  to  take  up  any  part  of  the  pure  food  and  drug 
work  will  obtain  copies  of  the  law,  directions  and  labels  for  taking 
samples,  containers  for  special  kinds  of  samples  and  all  needed 
information  on  applying  to  his  own  State  Board  of  Health. 

Pure  food  laws,  as  has  just  been  stated,  do  not  necessarily  con- 
cern themselves  with  the  surroundings  in  which  a  food  article  is 
made.  Sanitary  food  laws  do.  It  is  evidently  much  more  impor- 
tant that  a  dairyman,  for  instance,  should  produce  his  milk  under 
the  best  conditions,  so  that  it  has  a  low  bacterial  count,  than  that 
he  should  add  a  little  clean  water  to  it,  especially  if  it  be  a  very 
rich  milk  to  begin  with.  Hence,  the  sanitary  inspection  of  food  pro- 
ducing establishments  of  all  kinds  is  a  matter  to  be  attended  to 
with  scrupulous  care. 

General  Principles. — There  are  certain  general  principles  to  be 
followed  out  in  all  inspections  of  this  nature.  The  inspector  on 
entering  the  place  asks  for  the  proprietor  or  employee  in  charge, 

315 


316  PRACTICAL   SANITATION. 

states  the  nature  of  his  business,  and  if  asked  for,  shows  his  author- 
ity to  make  the  inspection.  Having  identified  himself,  any  attempt 
to  prevent  the  inspection  places  the  person  so  doing  in  the  position 
of  resisting  an  officer,  and  the  inspector  will  call  assistance  from 
constables,  the  sheriffs  and  deputies,  or  the  police.  In  some  states 
it  will  also  be  necessary  to  procure  a  search-warrant  owing  to  de- 
fectively drawn  laws.  Notice  of  any  kind  in  advance  of  the  inspec- 
tion is  manifestly  against  public  policy  and  is  never  given;  the 
notice  given  in  showing  the  authority  to  make  the  investigation  is 
sufficient. 

In  most  states  blank  forms  are  provided  for  this  work,  but  if  none 
is  provided,  the  inspector  may  follow  this  schedule. 

Inspector's  Number 

1.  Name  of  Owner.  2.  City  or  Town.  3.  County.  4.  Street 
and  Number.  5.  Date.  6.  Nature  of  business  as  bakery,  confec- 
tionery, drugstore,  slaughterhouse,  etc.  6.  Is  floor  clean?  Under 
this  head  it  is  important  to  look  for  evidences  of  expectora- 
tion, especially  behind  counters,  and  for  dust  and  dirt  everywhere. 
7.  Are  walls  and  ceilings  clean?  Smoked  ceilings  are  not  unsani- 
tary in  themselves,  but  are  evidence  of  a  slackness  in  matters  of 
cleanliness  which  is  something  of  an  index  to  other  conditions.  Fly- 
specked  walls  and  ceilings  always  show  carelessness  in  the  matter 
of  admitting  flies  to  the  place,  and  call  for  orders  looking  to  their 
exclusion.  8.  Are  shelves  and  counters  clean?  This  is  not  only  a 
matter  of  assthetics  but  a  matter  of  good  or  bad  sanitation.  9. 
Are  back  rooms  clean?  Many  establishments  which  look  all  right 
to  the  customer  have  very  dirty  hidden  places  which  it  is  the  duty 
of  the  inspector  to  find.  10,  Is  back  yard  tidy  ?  A  back  yard  that 
is  badly  cared  for  is  a  breeding  place  for  flies.  It  must  be  kept 
thoroughly  clean.  11.  Is  cellar  clean  and  tidy?  Like  other  out- 
of-sight  places,  the  cellar  is  prone  to  be  neglected,  and  is  one  of 
the  places  to  be  gone  over  with  the  greatest  care,  especially  if  food 
is  prepared  or  stored  in  it,  and  unless  it  is  thoroughly  well-lighted 
and  ventilated  either  preparation  or  storage  should  be  forbidden. 
12,  Are  toilets  provided  ?  This  expression  means  not  only  the  water 
or  other  closet,  but  proper  means  for  cleansing  the  hands  whenever 
they  become  soiled.  "Where  located?  The  closet  must  not  be 
located  in  such  a  way  that  it  communicates  directly  with  any  part 
of  the  establishment  where  food  is  prepared  or  stored.     The  lava- 


SANITARY  FOOD  [NSrECTION.  317 

tory  should  be  as  near  the  work  as  possible.  13.  Are  light  and 
ventilation  of  the  establishment  satisfactory  ?  14.  Are  screens  pro- 
vided? 15.  Are  flies  abundant?  16.  Are  spittoons  in  use?  They 
should  be  provided  and  should  be  cared  for  by  being  emptied  daily, 
washed  out  with  an  antiseptic  solution,  and  a  few  ounces  of  the 
solution  left  in.  17.  Are  employees  neat  and  clean?  18.  Appar- 
ently healthy?  Those  who  are  tubercular  should  not  assist  in  the 
care  or  sale  of  food  products,  for  their  own  sakes  as  well  as  that 
of  the  general  public.  19.  Is  any  of  the  rooms  used  as  a  sleeping 
room?  20.  Is  garbage  removed  daily?  21.  Is  the  water  supply 
abundant  and  good?     22.  Is  hot  water  available  whenever  needed? 

Special  questions  relating  to  different  kinds  of  establishments 
follow : 

Groceries  and  Meat  Markets. — Is  refrigerator  clean?  Musty? 
Slimy?  In  inspecting  refrigerators,  bread-boxes,  etc.,  the  nose  is 
a  much  better  detective  than  the  eye.  If  a  refrigerator  smells 
clean  it  is  almost  certainly  clean,  but  if  it  only  looks  clean,  it  may 
be  very  dirty  indeed  from  a  sanitary  standpoint.  Is  meat  slimy? 
Covered  with  mould?  Is  meat-block  clean  and  sweet?  Is  meat 
of  good  quality?  (This  subject  will  be  taken  up  in  detail  in  a 
later  paragraph  of  this  chapter.)  Is  meat  displayed  outside  shop? 
This  should  never  be  permitted,  as  it  is  thereby  exposed  to  dust  and 
flies.  Are  sausage,  etc.,  made  on  the  premises?  Are  lard  and 
tallow  rendered  on  premises?  Are  scraps  from  block  used  in 
sausage?  Rendered  for  food?  Provided  only  clean  scraps  are 
used  and  are  properly  cared  for  until  utilized,  there  is  no  objection 
to  their  utilization  in  sausage,  lard  or  other  food  products.  If 
they  are  so  used,  the  condition  of  the  stored  scraps  must  be  ascer- 
tained. Is  milk  sold?  If  sold,  is  it  properly  cared  for  in  a  sepa- 
rate ice-box  or  compartment?  Are  goods  protected  from  dogs? 
Are  dried  fruits  clean?  Is  confectionery  protected  from  flies  and 
dust?  Are  newspapers  used  for  wrapping?  This  is  a  very  bad 
practice. 

Hotels,  Eestaurants,  Ice  Cream  Parlors,  Lunch  Carts. — The 
remarks  in  the  last  paragraph  concerning  care  of  ice-boxes  and  of 
milk  apply  wdth  equal  force  to  this  class  of  business.  A  few  special 
questions  are  appended: 

Are  shelves,  tables  and  sinks  clean?  Are  dishes  and  tableware 
properly  washed?     Rinsed  in  hot  water?     Is  food  from  table  re- 


318  PRACTICAL   SANITATION. 

turned  to  kitchen  and  served  again?  Is  food  left  uncovered  on 
tables  or  shelves?  This  is  a  very  important  matter  as  flies  and 
dust  are  great  carriers  of  disease. 

Drug  Stores. — Is  soda  fountain  used?  Are  fountain  syrups 
made  or  bought?  Are  the  glasses  washed?  In  hot  water?  In 
running  water?  Are  goods  clean?  Fresh?  Is  prescription 
counter  clean?  Are  tinctures,  extracts,  etc.,  made?  Blought? 
Where  made  ?  Are  patents  properly  labeled  ?  This  clause  applies 
especially  to  the  content  of  alcohol,  morphine,  cocaine,  chloral, 
chloroform,  acetanilid,  etc.,  required  by  the  National  Food  and 
Drug  Act.     Is  candy  protected  from  dust  and  flies? 

Bakeries  and  Confectioneries. — Is  bake-shop  clean?  Are 
goods  properly  handled? 

Slaughterhouses. — Is  killing  floor  kept  clean?  Where  is 
rendering  done?  Where  are  hides  stored?  Is  offal  fed  on  prem- 
ises? Is  it  cooked  before  feeding?  If  uncooked,  it  affords  an 
excellent  means  for  inoculating  the  hogs  with  tapeworm,  trichinosis 
and  tuberculosis,  as  well  as  some  other  diseases  of  less  importance. 
Is  water  provided  for  cleaning  floor  and  walls?  Is  cooling-room 
provided?  Cold  storage  room?  Are  meats  inspected  by  (a) 
United  States  government  inspectors?  (b)  Local  inspectors? 
Where  are  condemned  carcasses  stored?  How  are  they  finally  dis- 
posed of?  The  only  fit  disposition  for  condemned  carcasses  and 
parts  of  carcasses  is  in  soap-grease  and  tankage.. 

Inspection  of  Foodstuffs. — This  is  a  very  important  part  of  the 
sanitarian's  duties.  He  can  assure  himself  without  calling  in  the 
aid  of  the  food  chemist,  that  food  is  clean,  undecomposed  so  far 
as  the  senses  can  tell,  not  frozen  improperly,  and  if  frozen  in  cold 
storage  and  exposed  for  sale  that  it  is  not  sold  for  fresh  goods,  not 
over-ripe  (fruit  and  vegetables)  and  that  it  is  properly  cared  for 
so  as  not  to  be  exposed  to  too  high  a  temperature,  or  to  flies  and 
dust. 

Condemnation  of  Food  Products. — The  machinery  for  this  varies 
with  locality.  In  some  places  food  inspectors  have  police  powers 
and  can  summarily  seize  the  material  for  condemnation  and  arrest 
the  man  in  charge.  In  others  he  must  file  a  complaint  and  take 
the  condemned  goods  before  a  justice  of  the  peace  or  police  judge 
who  issues  the  warrant  for  the  arrest  of  the  man  and  the  order  for 
the  destruction  of  the  spoiled  articles,  and  in  still  a  third  group 
of  places  the  inspector  can  seize  the  goods  without  warrant,  but 


SANITARY  POOD  INSPECTION.  319 

must  secure  a  warrant  for  the  arrest  of  the  owner.  In  many  cases 
a  judicious  threat  or  a  very  little  moral  suasion  will  induce  the 
man  to  destroy  the  unfit  goods,  especially  if  several  charges  can 
be  brought  against  him  and  he  thereby  secures  immunity  from  all 
but  one. 

Condemned  liquids  are  usually  disposed  of  by  emptying  into 
a  sewer  or  upon  the  ground ;  animal  foods  by  soaking  in  coal-oil 
before  sending  to  the  dump  or  crematory,  and  condemned  vege- 
tables and  fruits  by  dumping. 

It  should  be  remembered  that  all  decomposing  food  substances 
are  apt  to  cause  poisoning,  the  nature  and  severity  of  the  poisoning 
being  determined  by  the  bacterial  flora  present  and  by  the  stage 
of  decomposition.  Most  cases  of  food  poisoning  are  evidenced  by 
vomiting,  diarrhea,  chilliness  followed  by  elevation  of  temperature, 
cramps  in  the  abdomen  and  often  in  the  limbs  and  back,  and 
prostration.  Death  may  result,  and  when  many  persons  have 
partaken  of  the  affected  food,  the  cases  may  take  on  the  character- 
istics of  an  epidemic.  Meat  foods,  especially  sausage,  head  cheese, 
and  similar  made  dishes  are  particularly  liable  to  cause  such 
troubles;  while  milk,  ice  cream  and  cheese  are  even  more  so. 
Vegetable  foods  are  more  rarely  at  fault,  but  present  a  considerable 
number  of  cases  in  the  aggregate.  Two  or  three  micro-organisms 
have  been  isolated  from  sausage  which  had  caused  symptoms  of 
poisoning,  which  were  capable  of  reproducing  the  conditions. 
Vaughan's  pioneer  work  on  the  tyrotoxicon  poisoning  of  milk  and 
cheese  is  well  known.  Some  recent  researches  on  epidemic  jaundice 
(Weil's  disease)  seem  to  show  that  it  is  an  infection  by  the 
Bacillus  proteus  propagated  in  food.  More  specific  information  is 
catalogued  under  the  various  heads  in  the  following  portions  of  this 
chapter. 

Meat  Foods. — The  Indiana  State  Board  of  Health  defines  meat 
as  follows:  "Meat,  flesh,  is  any  clean,  sound,  dressed  and  properly 
prepared  edible  part  of  animals  in  good  health  at  the  time  of 
slaughter,  and  if  it  bears  a  name  descriptive  of  its  kind,  com- 
position or  origin,  it  corresponds  thereto.  The  term  'animals'  as 
herein  used,  includes  not  only  mammals,  but  fish,  fowl,  crustaceans, 
mdllusks  and  all  other  animals  used  for  food."  Any  meat  which 
corresponds  to  this  definition  will  be  safe  for  food.  Any  meat 
which  falls  short  of  it  in  any  degree  will  be  dangerous. 

Animals  may  be  inspected  before  or  after  slaughter.     If  in- 


320  PRACTICAL   SANITATION. 

spected  before  slaughter,  they  should  present  clear  eyes,  nostrils 
free  from  secretion,  smooth  coat  free  from  sores  or  scabs,  and  at 
least  a  moderate  amount  of  fat.  Practically  the  same  points  apply 
to  poultry. 

Injured  or  fatigued  animals,  those  too  young  or  too  old,  just 
before  or  just  after  parturition,  or  those  which  have  died  of  old 
age  or  other  causes,  are  unfit  for  food. 

The  symptoms  of  the  more  important  diseases  which  should 
condemn  animals  for  food  purposes  are  as  follows: 

Septicemia  and  Pyemia. — These  are  general  diseases,  evidenced 
by  abscesses,  prostration,  and  fever. 

Einderpest  (Cattle  Plague). — Prostration,  shivering,  discharge 
from  eyes,  nose  and  mouth  and  loss  of  appetite. 

Anthrax. — Localized  anthrax  is  shown  by  the  carbuncles,  boils 
and  pustules  as  in  human  anthrax.  General  anthrax  by  the  large 
pulpy  spleen.  In  case  of  doubt,  a  microscopic  examination  of  the 
pus  or  fluid  from  the  spleen,  and  if  the  case  is  positive  the  slaughter- 
house or  yards  should  be  condemned  until  thoroughly  cleaned  and 
disinfected.  This  disease  is  highly  dangerous  both  to  man  and  all 
animals  which  are  used  for  food,  and  the  flesh  of  infected  animals 
may  convey  the  disease  through  the  medium  of  bacilli  or  spores 
not  destroyed  in  cooking. 

Tuberculosis. — This  infects  almost  all  parts  of  the  animal, 
though  the  muscles  but  rarely.  It  is  to  be  recognized  by  the  tuber- 
culin test  in  its  earlier  stages,  but  in  the  later  stages,  the  rough 
coat,  emaciation,  cough,  weakness  and  loss  of  appetite,  together 
with  the  elevated  temperature  allow  the  diagnosis  to  be  made  by 
inspection,  at  least  so  far  as  to  condemn  the  animal  for  food. 

Texas  Fever. — High  fever,  prostration,  drooping  ears  and  tail, 
with  hind  legs  under  body.  The  disease  is  due  to  an  infection 
by  a  protozoon  (Pirosoma),  and  is  not  communicable  to  man  as 
such,  but  the  feverish  condition  of  the  animal  renders  it  unfit  for 
food. 

Pleuro-pneumonia. — The  symptoms  are  cough,  high  tempera- 
ture, and  difficult  breathing.  The  disease  is  limited  to  the  chest 
and  is  said  not  to  render  the  meat  unfit  for  food,  but  it  should 
ordinarily  be  condemned,  nevertheless. 

Foot  and  Mouth  Disease. — The  distinctive  symptom  of  this  dis- 
ease is  the  appearance  of  small  pustules  around  the  hoofs  and  mouth 
of   the   animal,   with   rough   coat   and   elevation   of   temperature. 


SANITARY  FOOD  INSPECTION.  .321 

Both  meat  and  milk  may  convey  the  infection,  which  is  occasionally 
fatal  in  very  young  children.     The  meat  should  be  condemned. 

Sheep-pox. — This  is  to  be  recognized  by  the  high  temperature, 
the  "flea-bitten"  coat  in  the  early  stage  and  later  by  the  pustules 
or  scabs. 

Liver  Flukes,  ''Sheep  Kot,"  "Measles,"  Trichinosis. — These 
diseases  are  described  at  some  length  in  Chapter  XIX.  If  the 
disease  is  not  too  pronounced,  animals  carrying  these  parasites  are 
fit  for  food,  provided  the  meat  is  thoroughly  cooked.  Unless  this 
is  done  by  "processing"  the  meat  at  the  abattoir,  the  meat  should 
be  condemned,  since  in  the  hands  of  careless  cooks  it  might  be 
served  without  sufficient  cooking. 

Hog  Cholera. — To  be  known  at  once  by  the  diarrhea.  Such 
animals  are  unfit  for  food. 

After  Slaughter. — Good  Meats  are  uniform  in  color,  neither  too 
dark  red  nor  too  pale,  firm  and  elastic  to  the  touch  and  moist  but 
not  wet.  It  should  neither  pit  nor  crackle  on  pressure,  and  should 
have  the  fat  distributed  in  a  marbled  appearance  through  it.  The 
odor  should  not  be  unpleasant,  and  the  reaction  should  be  slightly 
acid  to  litmus.     The  fat  should  be  firm  and  white,  without  running. 

Beef. — This  is  bright  red  and  firm,  and  more  marbled  than  other 
meats. 

Veal. — Paler  than  beef  and  not  so  firm.  It  should  be  from 
animals  not  less  than  six  weeks  old.  Unborn  or  "bob"  veal  is 
sometimes  sold.     It  should  be  condemned  and  the  vendor  prosecuted. 

Pork. — Pale  like  veal,  but  the  fat  is  firmer  as  well  as  the  lean. 

Mutton. — Dark  red  and  firm,  with  hard  fat,  whitish  or  yellowish 
in  color. 

Horse-flesh. — Coarser  and  darker  than  beef,  not  marbled,  and 
when  cooked,  sweetish  in  taste.  There  is  no  objection  to  its  sale 
if  sold  as  such,  provided  it  is  from  healthy  animals. 

Bad  Meats. — Meats  which  are  dark  in  color  or  purplish  are 
probably  from  animals  improperly  killed  and  bled,  or  from  animals 
killed  by  crowding  in  the  car  or  choked  to  death.  If  they  are 
flabby,  wet,  or  sodden,  with  alkaline  reaction  to  litmus  they  are 
decomposed,  and  should  be  condemned.  The  same  is  true  if  they 
crackle  on  pressure,  showing  gas  in  the  tissues,  or  if  the  flesh  tears 
easily,  or  the  fat  is  yellow  and  soft. 

Fish. — Good  fish  should  be  firm  and  elastic  to  the  touch,  and 
if  held  by  the  middle  should  remain  rigid.     The  gills  should  show 


322  PRACTICAL   SANITATION. 

a  bright  red  color  and  be  moist;  the  eyes  should  be  clear  and  "the 
overlying  skin  transparent.  The  odor  should  not  be  unpleasant, 
and  the  fish  should  sink  if  thrown  into  water.  Floating  is  evidence 
of  decomposition  of  dressed  fish  and  of  all  species  not  having  large 
swimming  bladders.  The  inspector  should  be  on  the  watch  for 
dealers  w-ho  attempt  to  give  stale  fish  an  appearance  of  freshness 
by  painting  the  gills  with  blood. 

Preservatives,  especially  sodium  sulphite,  are  used  not  to  make 
the  goods  keep  but  to  improve  the  appearance  of  stale  materials. 
Sulphites  give  to  meats,  especially  such  chopped  meats  as  sausage 
and  Hamburg  steak  which  are  often  made  of  stale  scraps,  a  redness 
like  that  of  fresh  material.  Samples  of  any  suspected  goods  should 
be  taken  and  turned  over  to  a  chemist  for  analysis. 

Milk  and  Dairy  Products  are  the  subject  of  a  special  chapter 
(Chapter  XXXVI). 

Fruits  should  be  carefully  inspected  for  over-ripeness,  greenness, 
or  decomposition.  Some  dealers  ripen  fruit  in  cellars,  bedrooms 
or  other  unfit  places,  and  polish  the  skin  by  rubbing  it  with  a  filthy 
cloth,  sometimes  with  spittle  as  a  lubricant.  Fruit  which  has  been 
frozen  should  be  guarded  against  as  very  apt  to  produce  intestinal 
derangements. 

Green  Vegetables  are  to  be  condemned  if  badly  wilted,  or  if 
marketed  in  the  winter,  frozen. 

Roots,  such  as  potatoes,  carrots,  dried  onions  and  so  on,  should 
be  condemned  if  frozen  or  decayed.  Potatoes  which  have  sprouted 
should  not  be  sold  for  food,  and  the  same  is  true  if  sunburned, 
as  they  are  bitter  and  develop  an  alkaloidal  poison  known  as  solanine 
which  is  capable  of  producing  severe  symptoms  and  death. 

Cereals  are  to  be  condemned  if  mouldy  or  weevilly.  This  is 
also  true  of  cereal  products  of  all  kinds,  such  as  bread,  pastry, 
crackers,  and  breakfast  foods. 

Eggs,  should  be  candled  before  sale  and  graded.  Those  grades 
which  show  large  aircells,  blood-spots,  cracks  and  so  on  are  not 
desirable  as  human  food,  but  should  find  a  place  in  the  arts.  Broken 
eggs  in  cans  are  almost  always  made  from  eggs  of  or  below  the 
grade  of  "thirds"  and  are  sold  by  the  packers  for  use  in  the  arts. 
If  found  in  bakeries,  they  should  be  seized.  If  brought  across  an 
interstate  line,  it  will  be  very  often  a  matter  for  the  United  States 
courts. 

Health  of  Employees. — It  goes  without  saying  that  persons  suf- 


SANITARY  FOOD  INSPECTION.  323 

fering  from  tuberculosis,  any  of  the  acute  infectious  diseases,  or 
known  to  be  carriers  of  typhoid,  dysentery  or  any  of  the  intestinal 
infections,  must  not  be  permitted  to  handle  or  sell  food  products. 
Many  epidemics  of  various  kinds  have  been  traced  to  this  source, 
and  purveyors  of  food  should  never  be  overlooked  in  the  search 
for  the  cause  of  an  epidemic. 

Food  Poisoning. 

Laboratory  examinations  in  cases  of  suspected  food  poisoning 
are  not  often  rewarded  with  definite  results.  This  is  due  in  part 
to  the  difficulty  in  getting  the  material  in  proper  condition,  in  part 
to  technical  difficulties  in  the  way,  and  in  part  to  the  confusion 
which  still  exists  in  regard  to  the  organisms  which  cause  food  poi- 
soning. It  is  generally  recognized  that  B.  enteritidis,  B.  hotulinus 
and  possibly  a  few  other  bacteria  are  capable  of  causing  the  pro- 
duction of  powerful  toxins  in  food  products,  especially  those  rich 
in  proteids,  in  which  they  grow,  but  numerous  cases  arise  in  which 
none  of  these  recognized  organisms  can  be  found. 

AYlien  food  suspected  of  causing  poisoning  is  to  be  examined,  as 
large  a  piece  of  the  suspected  material  as  possible  should  be  sent 
to  the  laboratory.  It  should  be  wrapped  in  sterile  cloths,  sealed 
in  a  sterile,  water-tight  container,  a  fruit  jar,  for  example,  and 
packed  in  ice  if  it  is  not  to  be  examined  immediately.  Every  effort 
should  be  made  to  prevent  any  further  contamination  with  extrane- 
ous bacteria  which  wall  only  make  the  examination  more  difficult. 
At  best,  the  examination  may  only  lead  to  indefinite  results ;  but  no 
health  officer  should  allow  a  ease  of  food  poisoning  in  his  jurisdic- 
tion go  without  some  investigation,  including  laboratory  examina- 
tion where  possible. 

Responsibility  and  Opportunity. 

Health  officers  frequentl}^  do  not  realize  either  their  responsibili- 
ties or  their  opportunities  in  connection  with  this  kind  of  work. 
Scarcely  any  line  of  sanitary  work  is  more  important  or  more 
prompt  to  yield  results  in  decreased  sickness-  and  death-rates. 
Valuable  assistance  can  often  be  secured  from  civic  organizations 
for  sanitary  food  work.  One  most  excellent  way  of  raising  the 
standard  of  food-producing  or  handling  establishments  is  the  use 
of  a  "white  list"  in  which  are  entered  the  names  of  all  those  food- 
merchants  whose  places  grade  "good"  or  better.     These  merchants 


324  PRACTICAL   SANITATION. 

are  given  a  white  card  to  hang  in  their  windows,  and  the  list  is 
published.  The  necessary  publicity  soon  forces  those  who  cannot 
grade  up  to  the  standard  to  improve  their  places  until  they  can, 
or  forces  them  to  quit  business. 


CHAPTER  XXXVI. 
MILK. 

The  proper  production  and  care  of  milk  is  an  absolute  necessity 
of  modern  civilization,  and  the  enforcement  of  regulations  designed 
to  secure  a  proper  milk  supply  is  probably  the  greatest  single  factor 
in  reducing  infant  mortality. 

To  this  end  a  complete  sanitary  survey  should  be  made  not  only 
of  the  dairy  farm,  but  of  the  milk  routes  and  every  place  where 
contamination  or  over-heating  of  the  milk  is  possible.  The  fol- 
lowing rules,  if  everywhere  enforced,  are  sufficient  to  secure  a 
uniformly  sound  milk  supply  and  thereby  save  thousands  of 
infant  lives  sacrificed  under  present  slipshod  and  careless  methods. 
A  detailed  schedule  for  grading  dairies,  founded  on  the  United 
States  Agricultural  Department  score-card  will  be  found  in  the 
Appendix.  By  its  use  even  an  inexperienced  health  officer  can 
make  a  good  sanitary  survey  of  a  dairy. 

Need  of  Milk  Control. — Proper  milk  standards,  while  they  are  essential 
to  etiieient  milk  control  by  public  health  autliorities  and  have  as  their  object 
the  protection  of  the  milk  consumer,  are  also  necessary  for  the  ultimate 
well-being  of  the  milk  industry  itself.  Public  confidence  is  an  asset  of  the 
highest  value  in  the  milk  business.  The  milk  producer  is  interested  in 
proper  standards  for  milk,  since  these  contribute  to  the  control  of  bovine 
tuberculosis  and  other  cattle  diseases  and  distinguish  between  the  good 
producer  and  the  bad  producer.  The  milk  dealer  is  immediately  classified 
by  milk  standards,  either  into  a  seller  of  first-class  milk  or  a  seller  of  second- 
class  milk,  and  such  distinction  gives  to  the  seller  of  first-class  milk  tiie 
conuuercial  rewards  which  he  deserves,  while  it  inflicts  just  penalties  on  the 
seller  of  second-class  milk.  For  mill<  consumers,  the  setting  of  definite 
standards  accompanied  by  proper  labeling  makes  it  possible  to  know  the 
character  of  the  milk  which  is  purchased  and  to  distinguish  good  milk  from 
bad  milk.  In  the  matter  of  public  health  administration,  standards  arc 
alisolutely  necessary  to  furnish  definitions  around  wiiicli  tlie  rules  and  regu- 
lations of  city  health  departments  can  be  drawn,  and  the  milk  supply  effi- 
ciently controlled. 

Public  Health  Authorities. — While  public  health  authorities  must  neces- 
sarily  see   that   the   source   of   supply   and  the   chemical   composition   slaould 

325 


326  PRACTICAL   SANITATION. 

corrospond  with  cstablisht'd  definitions  of  milk  as  a  food,  their  most  im- 
portant duty  is  to  prevent  the  transmission  of  disease  through  millc.  Ihis 
means  the  control  of  infantile  diarrhea,  typhoid  fever,  tuberculosis,  diph- 
theria, scarlet  fever,  septic  throat  infections,  and  other  infectious  diseases 
in  so  far  as  they  are  carried  by  milk. 

Septic  Sore  Throat. — Septic  sore  throat  deserves  special  mention  because 
of  the  fre(|uency  in  recent  years  with  which  outbreaks  of  this  disease  have 
been  traced  to  milk  supplies.  The  suggestion  has  been  made  that  the  in- 
fection of  the  milk  is  due  to  udder'  infection  of  the  cow  and  on  the  other 
hand  it  has  been  suggested  that  it  is  due  to  contact  with  infected  persons. 
Ihe  uncertainty  can  not  be  dispelled  until  cases  of  septic  sore  throat  are 
regularh'  reported  and  tabulated  by  public  health  authorities.  The  com- 
mission therefore  reconunends  that  public  health  authorities  make  septic 
sore   throat   a   reportable   disease. 

Legal  Requirements. — A  prime  requisite  of  effectiveness  is  that  local  milk 
laws  shall  not  exceed  sanitary  limitations.  The  commission  has  not  entered 
into  a  discussion  of  fundamental  State  laws,  but  it  recommends  that  State 
laws  be  amended  wherever  necessary  in  order  that  every  municipality  may 
have  the  legal  right  to  adopt  whatever  ordinances  it  sees  fit  for  the  improve- 
ment of  the  milk  supply.  The  commission  advocates  that  local  health  laws 
be  carefully  drawn  with  regard  to  their  legality  under  the  general  laws  of 
the  localities  to  which  they  apply,  since  a  decision  against  a  milk  law  in 
one  locality  is  liable  to  be  used  as  a  precedent  against  milk  laws  elsewhere. 

Classification  of  Milks. — There  is  no  escape  from  the  conclusion  that  milk 
must  be  graded  and  sold  on  grade,  just  as  wheat,  corn,  cotton,  beef,  and 
other  products  are  graded.  The  milk  merchant  must  judge  of  the  food 
value  and  also  of  the  sanitary  character  of  the  commodity  in  which  he  deals. 
The  high-grade  product  must  get  a  better  price  than  at  present.  The  low- 
grade  product  must  bring  less.  In  separating  milk  into  grades  jind  classes, 
the  commission  has  endeavored  to  make  its  classification  as  simple  as  pos- 
sible and  at  tlie  same  time  to  distinguish  between  milks  which  are  es- 
sentially   different    in    sanitary    character. 

In  general  two  great  classes  of  milk  are  recognized,  namely,  raw  milk  and 
pasteurized  milk.  Under  these  general  classes  there  are  different  grades,  as 
indicated  in  the  report  of  the  committee  on  classiffcation. 

Pasteurization. — While  the  process  of  pasteurization  is  a  matter  which 
has  attracted  a  great  deal  of  attention  in  recent  years,  the  commission  has 
not  entered  into  any  discussion  of  its  merits  or  demerits,  but  has  given  it 
recognition  in  its  classification  as  a  process  necessary  for  the  treatment 
of  milk   which  is  not  otherwise  protected  against  infection. 

Ihe  commission  tliinks  that  ])asteurization  is  necessary  for  all  milk  at 
all  times,  excepting  grade  A,  raw  milk.  The  majority  of  the  commissioners 
voted  in  favor  of  the  jiasteurization  of  all  milk,  including  grade  A.  raw  milk. 
Since  tiiis  was  not  uiiaiiiiiHUis  the  cf)mmiwsion  recommends  tliat  the  jiasteur- 
i:  ation   of  grade    A,   raw    milk,   be  optidiial. 

'Ihe  process  of  pasteurization  should  be  iuuUt  ollicial  supervision.  'J  Ik^ 
supervision  should  consist  of  a  personal  inspection  by  the  milk  inspector; 
the    inspections    shall    be    as    frequent    as    possible.     Automatic    temperature 


MILK.  ■  327 

regulators  and  ri't-urding  tliorniometcrs  should  bo  re(|uired  and  the  oflicicncy 
of  the  process  frequently  determined. 

Classification  of  Milk. — It  was  resolved  that  the  classification  of  milk  con- 
tained in  the  first  report  of  the  commission  be  amended  as  follows: 

Milk  shall  be  divided  into  three  grades,  which  shall  be  the  same  for  both 
large  and  small  cities  and  towns,  and  which  shall  be  designated  by  the 
first  three  letters  of  the  alphabet.     The  requirements  shall  be  as  follows; 

Grade  A. — Naic  mi]];. — Milk  of  this  class  shall  come  from  cows  free  from 
disease  as  determined  by  tuberculin  tests  and  physical  examinations  by  a 
qualified  veterinarian,  and  shall  l)e  produced  and  handled  by  employees  free 
from  disease  as  determined  by  medical  inspection  of  a  qualified  physician, 
under  sanitary  conditions  such  that  the  bacteria  count  shall  not  exceed 
100,000  per  cubic  centimeter  at  the  time  of  delivery  to  the  consumer.  It  is 
recommended  that  dairies  from  which  this  supply  is  obtained  shall  score  at 
least  80  on  the  United  States  Bureau  of  Animal  Industry  score  card. 

Pasteurized  mill:. — Milk  of  this  class  shall  come  from  cows  free  from  dis- 
ease as  determined  by  physical  examinations  by  a  qualified  veterinarian  and 
shall  be  produced  and  handled  under  sanitary  conditions  such  that  the  bac- 
teria count  at  no  time  exceeds  200,000  per  cubic  centimeter.  All  milk  of  this 
class  shall  be  pasteurized  under  official  supervision,  and  the  bacteria  count 
shall  not  exceed  10.000  per  cubic  centimeter  at  the  time  of  delivery  to  the 
consumer.  It  is  recommended  that  dairies  from  which  this  supply  is  ob- 
tained should  score  65  on  the  United  States  Bureau  of  Animal  Industry 
score  card. 

The  above  represents  only  the  minimum  standards  under  which  milk  may 
be  classified  in  grade  A.  The  commission  recognizes,  however,  that  there 
are  grades  of  milk  which  are  produced  under  unusuallj^  good  conditions,  in 
especially  sanitary  dairies,  many  of  which  are  operated  under  the  super- 
vision of  medical  associations.  vSuch  milks  clearly  stand  at  the  head  of.  this 
grade. 

Grade  B. — IMilk  of  this  class  shall  come  from  cows  free  from  disease  as 
determined  by  physical  examinations,  of  which  one  each  year  shall  be  by  a 
qualified  veterinarian,  and  shall  be  produced  and  handled  under  sanitary 
conditions  such  that  the  bacteria  count  at  no  time  exceeds  1,000,000  per  cubic 
centimeter.  All  milk  of  this  class  shall  be  pasteurized  under  official  super- 
vision, and  the  bacteria  coimt  shall  not  exceed  50,000  per  cubic  centimeter 
when  delivered  to  the  consumer. 

It  is  recommended  that  dairies  producing  grade  B  milk  should  be  scored 
and  that  the  health  departments  or  the  controlling  departments,  whatever 
they  may  be,  strive  to  bring  these  scores  up  as  rapidly  as  possible. 

Grade  C. — Milk  of  this  class  shall  come  from  cows  free  from  disease  as 
determined  by  physical  examinations  and  shall  include  all  milk  that  is  pro- 
duced under  conditions  such  that  the  bacteria  coimt  is  in  excess  of  1,000,000 
per   cubic   centimeter. 

All  milk  of  this  class  shall  be  pasteurized,  or  heated  to  a  higher  tempera- 
ture, and  shall  contain  less  than  50,000  bacteria  per  cubic  centimeter  when 
delivered  to  the  customer.  It  is  recommended  that  this  milk  be  used  for 
cooking  or  manufacturing  purposes  only. 


328  PRACTICAL   SANITATION. 

Whenever  any  large  city  or  comnmnity  finds  it  necessary,  on  account  of 
the  length  of  haul  or  otlier  peculiar  conditions,  to  allow  the  sale  of  grade 
C  milk,  its  sale  shall  be  surrounded  by  safeguards  such  as  to  insure  the  re- 
striction of  its  use  to  cools ing  and  manufacturing  purposes. 

Classification  of  Cream. — Cream  sliould  be  classified  in  the  same  grades 
as  milk,  in  accordance  with  tlie  requirements  for  the  grades  of  milk,  ex- 
cepting tlie  bacterial  standards  which  in  20  per  cent  cream  shall  not  exceed 
five  times  the  bacterial  standard  allowed  in  the  grade  of  milk. 

Cream  containing  other  percentages  of  fat  shall  be  alloAved  a  modifica- 
tion of  this  required  bacterial  standard  in  proportion  to  the  change  in  fat. 

Chemical  Standards. — Coir's  milk. — Standard  milk  should  contain  not  less 
than  8.5  per  cent  of  milk  solids  not  fat  and  not  less  than  3.2o  per  cent  of 
milk  fat. 

Bkim  milk. — Standard  skim  milk  sliould  contain  not  less  tlian  8.75.  per 
cent  of   milk   solids. 

Cream. — ^Standard  cream  contains  not  less  than  18  per  cent  of  milk  fat 
and  is  free  from  all  constituents  foreign  to  normal  milk.  Tlie  percentage  of 
milk  fat  in  cream  over  or  under  that  standard  should  be  stated  on  the  label. 

Buttermilk. — Buttermilk  is  the  product  that  remains  when  fat  is  removed 
from  milk  or  cream,  sweet  or  sour,  in  the  process  of  churning.  Standard 
buttermilk  contains  not  less  than  8.5  per  cent  of  milk  solids.  Wlien  milk 
is  skimmed,  soured,  or  treated  so  as  to  resemble  buttermilk,  it  should  be 
known  by  some  distinctive  name. 

Homogenized  Milk  or  Cream. — ^The  commission  is  of  the  opinion  that  in 
tlie  compounding  of  millv  no  fats  other  than  milk  fats  from  the  milk  in 
process  should  be  used  and  that  no  substance  foreign  to  milk  should  be  added 
to  it.  Tlie  commission  is  opposed  to  the  use  of  condensed  milk  or  other 
materials  for  the  tliickening  of  cream  unless  the  facts  are  clearly  set  forth  on 
the  label  of  the  retail  package.  Regarding  the  process  of  liomogenizing, 
the    commission    resolved    as    follows: 

Tliat  homogenized  milk  or  cream  sliould  be  so  marked,  stating  the  per- 
centage of  fat  that  it  contains. 

Adjusted  Milks. — On  the  question  of  milks  and  creams  in  which  the  ratio 
of  the  fats  to  the  solids  not  fat  has  been  changed  by  the  addition  to  or  sub- 
traction of  cream  or  milk  fat  the  commission  has  hesitated  to  take  a  posi- 
tion. On  the  one  hand  they  are  in  favor  of  every  procedure  which  will  in- 
crease the  market  for  good  milk  and  make  the  most  profitable  use  of  every 
portion  of  it.  On  the  other,  they  recognize  the  sensitiveness  of  milk,  the 
ease  with  which  it  is  contaminated,  and  the  difficulty  of  controlling  standard- 
izing, skimming,  homogenizing,  souring,  etc.,  so  that  contaminations  do  not 
occur  and  inferior  materials  are  not  used.  On  this  subject  the  commission 
passed  a  resolution  presented  by  a  special  committee  as  follows: 

Milk  in  which  the  ratio  of  the  fats  to  the  solids  not  fat  has  been  changed 
by  the  addition  to  or  "subtraction  of  cream  sliould  be  labeled  "adjusted  milk"; 
the  label  should  show  the  minimum  guaranteed  percentage  of  fat  and  should 
comply  with  the  same  sanitary  or  chemical  requirements  as  for  milk  not 
so  standardized  o)-  modified. 

Regulation  of  Market  Milk  on  Basis  of  Guaranteed  Percentage  Composi- 


MILK.  329 

tion. — 1.  Sellers  of  milk  should  be  permitted  choice  of  one  of  two  systems 
in  handling  market  milk.  Milk  can  be  sold,  first,  under  the  regular  standard, 
or,   second,  imder   a  guaranteed  statement  of  composition. 

2.  Any  normal  milk  may  be  sold  if  its  per  cent  of  fat  is  stated.  In  case 
the  per  cent  of  fat  is  not  stated,  the  sale  will  be  regarded  as  a  violation  un- 
less the  milk  contains  at  least  3.25  per  cent  of  milk  fat. 

3.  As  a  further  protection  to  consumers,  it  is  desirable  that  when  the 
guaranty  system  is  used  there  be  also  a  minimum  guaranty  of  milk  solids 
not  fat  of  not  less  than  8.5  per  cent. 

4.  Dealers  electing  to  sell  milk  under  the  guaranty  system  should  be  re- 
quired to  state  conspicuously  the  guaranty  on  all  containers  in  which  such 
milk  is  handled  by  the  dealer   or   delivered  to  the  consumer. 

5.  The  sale  of  milk  on  a  guaranty  system  should  be  by  special  permission 
obtained   from   some  proper   local   authority. 

Licenses. — Ixeqtiirenients. — No   person    shall   engage   in   the   sale,   handling, 

or   distribution   of  milk  in  until  he  has   obtained  a  license  therefor 

from    the    health    authorities.     This    license   shall   be    renewed    on    or    before 

the  1st  day  of  — ■ of  each  year  and  may  be  suspended  or  revoked  at  any 

time  for   cause. 

Recommendations. — The  application  for  the  license  shall  include  the  fol- 
lowing statements: 

( 1 )  Kind  of  milk  to  be  handled  or  sold. 

(2)  Names  of  producers  with  their  addresses  and  permit  numbers. 

(3)  Names   of   middlemen   with   their   addresses. 

(4)  Names  and  addresses  of  all  stores,  hotels,  factories,  and  restaurants 
at  which  milk  is  delivered. 

(5)  A  statement  of  the  approximate  number  of  quarts  of  milk,  cream, 
buttermilk,   and   skim  milk   sold   per   day. 

(6)  Source  of  water  suj^ply  at  farms  and  bottling  plants. 

( 7 )  Permission  to  inspect  all  local  and  out-of-to^^^l  premises  on  which  milk 
is  produced  and  handled. 

(8)  Agreement  to  abide  by  all  the  provisions  of  State  and  local  regula- 
tions. 

Permits. — Requirements. — No  person  shall  engage  in  the  production  of 
milk  for  sale  in  — — — ,  nor  shall  any  person  engage  in  the  handling  of  milk 

for  shipment  into  until  he  has  obtained  a  permit  therefor  from  the 

health  authorities.     This  permit  shall  be  renewed  on  or  before  the   1st  day 

of  •  of  each  year   and  may  be  suspended  or  revoked  at  any  timer  for 

cause. 

Raw  Milk. 
Cow  Stables. — Requirements. — 1.  They  shall  be  used  for  no  other  purpose 
than  for  the  keeping  of  cows,  and  shall  be  light,  well  ventilated,  and  clean. 

2.  They  shall  be  ceiled  overhead  if  there  is  a  loft  above. 

3.  The  floors  shall  be  tight  and  sound. 

4.  The  gutters   shall   be  water-tight. 

Recommendations. — 1.  The  window  area  shall  be  at  least  2  square  feet  per 
500   cubic  feet  of   air   space  and  shall  be  tmiformly  distributed,   if   possible. 


330 


PRACTICAL   SANITATION. 


If  imiform  distribution  is  impossible,  sufficient  additional  window  area  must 
be  provided  so  that  all  portions  of  the  barn  shall  be  adequately  lighted. 

•2.  The  amount  of  air  space  shall  be  at  least  500  cubic  feet  per  cow,  and 
adequate  ventilation   besides  windows   shall  be  provided. 

3.  The  walls  and  ceilings  shall  be  whitewashed  at  least  once  every  six 
months,  unless  the  construction  renders  it  unnecessary,  and  shall  be  kept 
free  from  cobwebs  and  dirt. 


^ ''''•'"= 


' '■■''"'''''ilipiiiplrjifi 


Pig.   33.- — Sanitary   cow  barn.      "Where   cleanliness   is   a   religion." 
(Courtesy,   Dr.  Henry  E.  Tuley.) 

4.  All  manure  shall  l)e  removed  at  least  twice  daily,  and  disposed  of  so 
as  not  to  be  a  source  of  danger  to  the  milk  either  as  furnisliing  a  breeding 
place  for   flies  or  otlierwise.  *. 

5.  Horse  manure  shall  not  be  used   in   the  cow  stable  for  any  purpose. 
Milk   Room. — Ref/uirements. — Every   milk   fariii    shall   be   provided   with   a 

milk   room  that  is  clean,  light,  and  well   screened.     It  shall  be  used  for  no 


MILK. 


331 


other   purpose  than   for   the  cooling,   bottling,   and   storage   of   milk   and  the 
operations  incident  thereto. 

Jiecommendatiovs. — 1.  It  shall   liave  no   direct   connection   with   any   stable 
or  dwelling. 


Fig.   34. — Immaculate   milking   conditions.      (Courtesy,   Dr.    Henry   E.   Tuley.) 


2.  The   floors   shall   be   of   cement   or   other   impervious   material,    properly 
graded  and  drained. 

3.  It  shall  be  provided  with  a  sterilizer  unless  the  milk  is  sent  to  a  bottling 
plant,  in  which  case  the  cans  shall  be  sterilized  at  the  plant. 

4.  Cooling  and  storage  tanks  shall  be  drained  and  cleaned  at  least  twice 
each  week. 

5.  All    drains    shall    discharge   at    least    100    feet    from    any   milk   house   or 
cow  stable. 

Cows. — Requirements. — 1.  A    physical    examination    of    all    cows    shall    be 


332  PRACTICAL   SANITATION. 

made  at  least  once  every  six  months  by  a  veterinarian  approved  by  the  health 
authorities. 

2.  Every  diseased  cow  shall  be  removed  from  the  herd  at  once  and  no 
milk  from  such  cows  shall  be  offeied  for  sale. 

3.  Ihe  tuberculin  test  sliall  be  applied  at  least  once  a  year  liy  a  veteri- 
narian   approved    by    the    health    authorities. 

4.  All  cows  which  react  shall  be  removed  from  the  herd  at  once,  and  no 
milk   from  such  cows  shall  be  sold  as  raw  milk. 

f).  No  new  cows  shall  be  added  to  a  herd  until  they  have  passed  a  physical 
examination   and   the   tuberculin   test. 

(5.  Cows,  especially  tlie  udders,  shall  be  clean  at  the  time  of  milking. 

7.  No  milk  that  is  obtained  from  a  cow  within  15  days  before  or  5  days 
after  parturition,  nor  any  milk  that  has  an  unnatural  odor  or  appearance, 
shall  be  sold. 

8.  No  unwholesome  food  shall  be  used. 

ReGommendations. — 1.  Every  producer  shall  allow  a  veterinarian  employed 
by  the  health  authorities  to  examine  his  herd  at  any  time  under  the  penalty 
of  having  his  supply  excluded. 

2.  Certificates  showing  the  results  of  all  examinations  shall  be  hied  with 
the  health  authorities  within   10  days  of  such  examinations. 

3.  Ihe  tuberculin  tests  shall  be  applied  at  least  once  every  six  months 
by  a  veterinarian  approved  by  the  health  authorities,  unless  on  the  previous 
test  no  tuberculosis  was  present  in  the  herd  or  in  the  herds  from  which -new 
cows  were  obtained,  in  which  event  the  test  may  be  postponed  an  additional 
six  months. 

4.  Charts  showing  the  results  of  all  tuberculin  tests  shall  be  filed  with 
the  health  authorities  within   10  days  of  the  date  of  such  test. 

5.  The  udders  shall  be  washed  and  wiped  before  milking. 

Employees. — Requirements. — 1.  All  employees  connected  in  any  way  with 
the  production  and  handling  of  milk  shall  be  personally  clean  and  shall 
wear  clean  outer  garments. 

2.  The  health  authorities  shall  be  notilied  at  once  of  any  communicable 
disease  in  any  person  that  is  in  any  way  connected  with  the  production  or 
handling  of  milk,  or  of  the  exposure  of  such  person  to  any  comnuinicable 
disease. 

3.  Milking  shall   be  done  only   with   dry   hands. 

liec(ymniendaiions. — 1.  Clean  suits  shall  be  put  on  immediately  liefore 
milking. 

2.  The  hands  shall  be  washed  inunediately  before  milking  each  cow,  in 
order  to  avoid  conveyance  of  infection  to  the  milk. 

Utensils. — Requirements. — 1.  All  utensils  and  apparatus  witli  whicli  milk 
comes  in  contact  sliall  be  thoroughly  washed  and  sterilized,  and  no  milk 
utensil  or  apparatus  sliall  l)e  used  for  any  other  purpose  than  that  for 
whieli   it  was  designed. 

2.  The  owner's  name,  license  number,  or  other  identification  mark,  the 
nature  of  which  shall  be  made  known  to  the  health  aiithorities,  shall  appear 
in  a  conspicuous  place  on  every  milk  container. 

3.  No  Ijottle  or  can  shall  be  removed  from   a  liouse  in  which  there  is,  or 


MILK.  -  333 

ill  whieh  tliore  has  recently  been,  a  case  of  eoiiimunicable  disease  until   per- 
mission  in  writing  has  been  granted  by  the  health  authorities. 

4.  All  metal  containers  and  piping  shall  be  in  good  condition  at  all  times. 
All  piping  shall  be  sanitarj-  milk  piping,  in  couples  short  enough  to  l)e 
taken   apart  and  cleaned  with   a  brush. 

5.  Small-toj)   milking  pails   shall   be   used. 

Reeommendations. — 1.  All  cans  and  bottles  shall  be  cleaned  as  soon  as 
possible  after   being  emptied. 

2.  Every  conveyance  used  for  the  transportation  or  delivery  of  milk,  public 
carriers  excepted,  shall  bear  the  owner's  name,  milk-license  number,  and 
business  address  in  unc(3ndensed  gotliic  characters  at  least  2  inches  in  height. 

Milk. — h'eqitireinents. — 1.  It  shall  not  be  strained  in  the  cow  stable,  but 
shall  be  removed  to  the  milk  room  as  soon  as  it  is  drawn  from  the  cow. 

2.  It  shall  be  cooled  to  50°  F<  or  below  within  two  hours  after  it  is  drawn 
from  the  cow  and  it  shall  be  kept  cold  until  it  is  delivered  to  the  consu- 
mer. 

3.  It  shall  not  be  adulterated  by  the  addition  to  or  the  subtraction  of 
any  substance  or  compound,  except  for  the  production  of  the  fluid  derivatives 
allowed  by  law. 

4.  It  shall  not  be  tested  by  taste  at  any  bottling  plant,  milk  house,  or 
other  place  in  any  way  that  may  render  it  liable  to  contamination. 

5.  It  shall  be  bottled  only  in  a  milk  room  or  bottling  plant  for  which  a 
license   or   permit  has   been   issued. 

0.  It  shall  be  delivered  in  bottles,  or  single  service  containers,  with  the 
exception  that  20  quarts  or  more  may  be  delivered  in  bulk  in  the  follow- 
ing cases : 

(a)  To  establishments  in  which  milk  is  to  be  consumed  or  used  on  the 
premises. 

(6)  To  infant-feeding  stations  that  are  under  competent  medical  super- 
vision. 

7.  It  shall  not  be  stored  in  or  sold  from  a  living  room  or  from  any  other 
place   which   might   render   it   liable   to   contamination. 

Kecommendations. — 1.  It  shall  be  cooled  to  50°  F.  or  below  immediately 
after  milking  and  shall  be  kept  at  or  below  that  temperature  until  it  is  de- 
livered   to    the    consumer. 

2.  It  shall  contain  no  visible  foreign  material. 

.3.  It  shall  be  labeled  with  the  date  of  production. 

Receiving'  Stations  and  Bottling  Plants. — Requirements. — 1.  They  shall  be 
clean,  well  screened,  and  lighted,  and  shall  be  used  for  no  other  purpose 
than  the  proper  handling  of  milk  and  the  operations  incident  thereto,  and 
shall  be  open  to  inspection  by  the  health  authorities  at  any  time. 

2.  They  shall  have  smooth,  impervious  floors,  properly  graded  and  drained. 

3.  They  shall  be  equipped  with  hot  and  cold  water  and  steam. 

4'.  Ample  provision  shall  be  made  for  steam  sterilization  of  all  utensils, 
and  no  empty  milk  containers  shall  be  sent  out  until  after  such  steriliza- 
tion. 

5.  All  utensils,  piping,  and  tanks  shall  be  kept  clean  and  shall  be  sterilized 
daily. 


334  PRACTICAL    SANITATION. 

Recommendations. — 1.  Containers  and  xitensils  shall  not  be  washed  in  the 
same  room  in  which  milk  is  handled. 

Stores. — Requirements. — 1.  All  stores  in  which  milk  is  handled  shall  be 
jirovided  with  a  suitable  room  or  compartment  in  which  the  milk  shall  be 
kept.  Said  compartment  shall  be  clean  and  shall  be  so  arranged  that  the 
milk  will  not  be  liable  to  contamination  of  any  kind. 

2.  Milk  shall  be  kept  at  a  temperature  not  exceeding  50°  F. 

Recommendations. — 1.  Milk  to  be  co'nsumed  off  the  premises  may  be  sold 
from    stores   only    in    the   original   unopened    package. 

General  Reg-iilations. — Requirements. — 1.  The  United  States  Bureau  of 
Animal  Industry  score  card  shall  be  used,  and  it  is  recommended  that  dairies 
from  which  milk  is  to  be  sold  in  a  raw  state  shall  score  at  least  80  points. 

2.  Every  place  where  milk  is  produced  or  handled  and  every  conveyance 
used  for  the  transportation   of  milk  shall  be  clean. 

3.  All  water  supplies  shall  be  from  uncontaminated  sources  and  from 
sources   not   liable   to   become   contaminated. 

4.  The  license  or  permit  shall  be  kept  posted  in  a  conspicuous  place  in 
every  establishment  for  the  operation  of  which  a  milk  license  or  permit  is 
required. 

5.  No  milk  license  or  permit  shall  at  any  time  be  used  by  any  person  other 
than  the  one  to  whom   it  was  granted. 

6.  No  place  for  the  operation  of  which  a  license  or  permit  is  granted  shall 
be  located  within  100  feet  of  a  privy  or  other  possible  source  of  contamina- 
tion, nor  shall  it  contain  or  open  into  a  room  which  contains  a  water- 
closet. 

7.  No  skim  milk  or  buttermilk  shall  be  stored  in  or  sold  from  cans  or 
other  containers  unless  such  containers  are  of  a  distinctive  color  and  per- 
manently and  conspicuously  labeled  "skim  milk"  or  "buttermilk,"  as  the 
case  maj'  be. 

8.  No  container  sliall  be  used  for  any  otlier  purpose  than  that  for  which 
it  is  labeled. 

Recommendations. — 1.  Ice  used  for  cooling  ]Hirposes  shall  be  dean  and  un- 
contaminated. 

2.  No  person  wliose  presence  is  not  required  shall  be  permitted  to  remain 
in  any  cow  stable,  milk  house,  or  bottling  room. 

Subnormal  Milk. — Requirements. — 1.  Natural  milk  that  contains  less  than 
3.25  ]jer  cent,  but  more  than  2.5  per  cent  milk  fat,  and  that  complies  in  all 
other  respects  with  the  requirements  above  set  forth,  may  be  sold,  ])rovided 
the  percentage  of  fat  does  not  fall  below  a  definite  percentage  that  is  stated 
in  a  conspicuous  manner  on  the  container;  and  further  provided  that  such 
container   is   conspicuously   marked   "substandard   milk." 

Cream. — Requirements  and  Recomtmendations. — 1.  It  shall  be  obtained  from 
milk  that  is  produced  and  handled  in  accordance  witli  the  provisions  herein- 
before set  forth   for  the  production   and  handling  of  milk. 

Standards  for  Milk. — Requirements. — 1.  It  shall  not  contain  more  than 
lOO.OOO   haclcria  ]>er   (•ul)ic  centimeter. 

2.  It  shall  contain  not  less  than  3.25  i)er  cent  milk  fat. 

3.  It  shall  contain  not  less  than  8.5  per  cent  solids  not  fat. 


MILK.  335 

I'ccdiniiundations. — 1.  Tlie  bactorial  limit  shall  be  lowered  if  possible. 

Standards  for  Cream. — Requirements. — 1.  There  shall  be  a  bacterial  stand- 
ard for  ereaiii  corresponding  to  the  grade  of  milk  from  which  it  is  made 
and  to  its  butter-fat  content. 

2.  It  shall  contain  not  less  than    IS  per  cent  milk  fat. 

J\'(ri)))h))ieiidatiovs. — Same   as   above   for   milk. 

Standards  for  Skim  Milk. — Requirements. — 1.  It  shall  contain  not  less 
than  8.75  per  cent  milk  solids. 

2.  Control  of  sale  of  skim  milk :  \Yhether  skim  milk  is  sold  in  wagons 
or  in  stores,  all  containers  holding  skim  milk  should  be  painted  some  bright, 
distinctive  color  and  prominently  and  legibly  marked  "skim  milk."  When 
skim  milk  is  placed  in  the  buyer's  container,  a  label  or  tag  bearing  the 
words  "skim  milk"  should  be  attached. 

Pasteurized  Milk. 

Pasteurized  milk  is  milk  that  is  heated  to  a  temperature  of  not  less  than 
140°  F.  for  not  less  than  20  minutes,  or  not  over  155°  F.  for  not  less  than 
5  minutes,  and  for  each  degree  of  temperature  over  140°  F.  the  length  of 
time  may  be  1  minute  less  than  20.  Said  milk  shall  be  cooled  immediately 
to  50°  F.  or  below  and  kept  at  or  below  that  temperature. 

Cow  Stables. — Requirements. — The  same  as  for  the  production  of  raw  milk. 

Recomuundatio'ris. — The  same  as  for  the  production  of  raw  milk. 

Milk  Room. — Requirements. — ^The  same  as  for  the  production  of  raw  milk. 

Reco)nmendations. — ^The  same  as  for  the  production  of  raw  milk. 

Cows. — Requirements. — The  same  as  for  the  production  of  raw  milk,  with 
the  exception  of  the  sections  relating  to  the  tuberculin  test. 

Recommendations. — That  no  cows  be  added  to  a  herd  excepting  those 
found  to  be  free  from  tuberculosis  by  the  tuberculin   test. 

Employees. — Requirements. — The  same  as  for  the  production  of  raw  milk. 

Recommendations. — The  same  as  for  the  production  of  raw  milk. 

TTtensils. — Requirements. — The  same  as  for  the  production  of  raw  milk. 

Recommendations. — ^The  same  as  for  the  2>roduction  of  raw  milk. 

Milk  for  Pasteurization. — Requirements. — 1.  The  same  as  for  the  pro- 
duction of  raw  milk,  with  the  exception  of  sections   1,  2,  and  6b. 

2.  It  shall  be  cooled  to  60°  F.  or  below  \Adthin  two  hours  after  it  is  drawn 
from  the  cow,  and  it  shall  be  held  at  or  below  that  temperature  until  it  is 
pasteurized.  After  pasteurization,  it  shall  be  held  at  a  temperature  not 
exceeding  50°   F.   until  delivered  to  the  consumer. 

3.  Pasteurized  milk  shall  be  distinctly  labeled  as  such,  together  with  the 
temperature  at  which  it  is  pasteurized  and  the  shortest  length  of  exposure 
to  that  temperature  and  the  date  of  i^asteurization. 

Recommendations. — 1.  No   milk   shall  be   repasteurized. 

2.  The  requirements  governing  the  production  and  handling  of  milk  for 
pasteurization   should  be  raised  wherever   practicable. 

Pasteurizing  Plants. — Requirements. — The  same  as  under  'Receiving  sta- 
tions and  bottling  plants"  for  raw  milk. 

Recomniendations. — The  same  as  under  "Receiving  stations  and  bottling 
plants"  for  raw  milk. 


336  PRACTICAL   SANITATION. 

Stores. — J\e(jiiireinents. — The  same  as  for  raw  milk. 

Jxecoiniiiendations. — The  same  as  for  raw  milk. 

General  Regulations. — liequirements. — 1.  It  is  recommended  that  dairies 
producing  milk  which  is  to  be  pasteurized  shall  be  scored  on  the  United 
States  Bureau  of  Animal  Industry  score  card,  and  that  health  departments, 
or  the  controlling  departments  -whatever  they  may  be,  strive  to  bring  these 
scores  up  as  rapidly  as  possible. 

2.  Milk  from  cows  that  have  been  rejected  by  the  tuberculin  test,  bvit  which 
show  no  physical  signs  of  tuberculosis,  as  well  as  those  which  have  not  been 
tested,  may  be  sold  provided  that  it  is  produced  and  handled  in  accordance 
with  all  the  other  requirements  herein  set  forth  for  pasteurized  milk. 

3.  Ice  used  for   cooling  purposes  shall  be   clean. 
Becommendations. — The  same  as  for  raw  milk. 

Pasteurized  Cream. — Requirements. — 1.  It  shall  be  obtained  only  from  milk 
that  could  legally  be  sold  as  milk  under  the  requirements  hereinbefore  set 
forth. 

2.  Pasteurized  cream,  or  cream  separated  from  pasteurized  milk,  shall  be 
labeled  in  the  manner  herein  provided  for  the  labeling  of  pasteurized  milk. 

Standards  for  Pasteurized  Milk.^ — Requirements. — 1.  It  shall  not  contain 
more  than  1,000,000  bacteria  per  cubic  centimeter  before  pasteurization,  nor 
over  50,000  when  delivered  to  the  consumer. 

2  The  standards  for  the  percentage  of  milk  fat  and  of  total  solids  shall 
be  the  same  as  for  raw  miUc. 

Recommendations. — 1.  The  limits  for  the  bacterial  count  before  jiasteuriza- 
tion  and  after  pasteurization  should  both  be  lowered  if  possible. 

Standards  for  Pasteurized  Cream. — Requirements. — 1.  No  cream  shall  be 
sold  that  is  obtained  from  pasteurized  milk  that  could  not  be  legally  sold 
under  the  provisions  herein  set  forth,  nor  shall  any  cream  that  is  pasteurized 
after  separation  contain  an  excessive  number  of  bacteria. 

2.  There  shall  be  a  bacterial  standard  for  pasteurized  cream  corrcsi)onding 
to  the  grade  of  milk  from  which  it  is  made  and  to  its  butterfat  content. 

.3.  The  percentage  of  milk  fat  shall  be  the  same  as  for  raw  cream. 

Penalty. 

Penalty. — Every  milk  ordinance  should  contain  a  penalty  clause. 


MILK. 


337 


TIML    AND    TLMPLRATURL     FOR 
,%'  MILK    PASTEURIZATION. 


FAT 
5UGAR 
CA5E.m 

5ALT,3 


TA5TL 


ALBUMEJS 
CREAM  LINE. 


TUBERCULOSIS 

TYPHOID 
57Rtprococt( 


DIPHTHERIA 


C.F  MorTliJ9l2. 


ro'  10'  30  40' 

T\  nt   IN    MINUTL5 


50' 


00' 


338 


PRACTICAL    SANITATION. 


Test  for  Skimmed  Milk. — Since  the  cream  or 
milk  fat  is  the  most  valuable  portion  of  the 
milk  and  at  the  same  time  is  the  part  most  easily 
abstracted,  the  sanitary  officer  will  do  well  to  be 
on  his  guard  against  partly  skimmed  milk  be- 
ing sold  for  whole  milk.  He  will  be  able  to 
make  this  test  very  readily  with  the  small  Bab- 
cock  apparatus  which  is  nowadays  to  be  found 
on  any  up-to-date  farm.  This  costs  from  $10.00 
to  $15.00  to  install  and  practically  nothing  for 
maintenance  thereafter. 

Chemical  Analysis. — The  chemical  analysis  of 
milk  includes  the  determination  of  the  per- 
centage of  fat,  proteid  and  sugar  in  milk  and 
the  detection  of  any  preservatives  or  coloring 
matter.  Chemical  examinations  of  milk  are, 
therefore,  of  more  economic  than  sanitary  im- 
portance. They  are  usually  made  with  the  ob- 
ject of  ascertaining  whether  the  dairyman  con- 
forms to  the  law  in  furnishing  milk  which 
contains  the  prescribed  per  cent  of  fat  and  is 
free  from  prohibited  preservatives. 

Samples  of  milk  intended  for  chemical  anal- 
ysis should  be  obtained  as  nearly  as  possible  in 
the  manner  in  which  it  is  received  by  the  or- 
dinary consumer.  If  milk  sold  in  bulk  is  to  be 
examined  it  should  be  stirred  until  the  cream  is 
thoroughly  mixed  before  taking  the  sample.  It 
is  important  that  milk  for  chemical  analysis 
be  kept  sweet  until  examined.  An  analysis  of  sour  milk  cannot 
be  as  accurate  and  as  fair  as  an  analysis  of  sweet  milk.  If  it  can- 
not be  examined  for  several  hours  after  collection,  the  sample 
should  be  kept  packed  in  ice. 

It  is  unnecessary  to  discuss  the  interpretation  of  the  results  of  a 
chemical  analysis  of  milk.  The  legal  chemical  standards  for  milk 
vary  in  different  cities  and  states.  The  health  officer  should  ac- 
quaint himself  with  these  requirements  in  his  own  jurisdiction. 
When  he  receives  from  the  chemical  laboratory  a  report  showing 
that  the  milk  furnished  by  a  certain  dairy  is  not  up  to  the  standard, 
his  duty  under  the  law  is  usually  clear. 


Fig.    35. — Babcock   but- 
ter  fat  tester. 


MILK, 


339 


Preservatives. — The  use  of  illegal  preservatives  in  milk  is  very 
much  less  common  than  it  was  a  few  years  ago.  In  case  their  pres- 
ence is  suspected  in  a  sample  of  milk,  it  should  be  set  to  one  side 
in  a  warm  place  for  48  hours,  and  if  by  that  time  it  has  not  soured, 
the  use  of  a  preservative  is  pretty  certain  and  samples  should  be 
sent  to  the  State  Laboratory,  or  the  follo^ving  tests  used: 

Test  for  Formaldehyd  in  Milk. — Commercial  sulphuric  acid  to 
which  has  been  added  5  drops  of  tincture  of  the  chloride  of 
iron  to  the  ounce  is  the  reagent.  A  half-inch  layer  of  this  is  put 
into  a  test  tube  and  the  milk  flowed  on  top.  After  a  few  minutes  a 
violet  color  develops  in  the  milk.  The  test  should  first  be  tried 
with  milk  known  to  contain  formaldehyd  and  after  the  reaction  is 
understood,  it  will  be  found  very  easy  to  apply. 

Boric  Acid  and  Borates. — ]\Iilk  containing  boric  acid  or  borates 
colors  tumeric  paper  brown. 

The  great  objection  to  the  use  of  preservatives  is  that  they  inhibit 
only  the  milk-souring  Bacillus  lactis  Avithout  interfering  to  any 
great  extent  with  many  pathogenic  bacteria. 

Test  for  Coloring  Matter. — The  presence  of  foreign  coloring  mat- 
ter in  milk  is  easily  shown  by  shaking  10  c.  c.  of  the  milk  with  an 
equal  quantit.y  of  ether ;  on  standing,  a  clear  ether  solution  will  rise 
to  the  surface ;  if  artificial  coloring  matter  has  been  added  to  the 
milk,  the  solution  will  be  yellow  colored,  the  intensity  of  the  color 
indicating  the  quantity- added;  natural  fresh  milk  will  give  a  color- 
less ether  solution.  {Testing  Milk  and  its  Froducts,  Farrington 
and  Wolh  p.  244.) 

Composition. — The  milk  from  cows  of  different  breeds  contain 
the  same  ingredients,  but  in  different  proportions,  as  shown  by  the 
following  table,  the  results  of  quantitative  analysis : 


DURHAM 

OR 
SHORT- 
HORN 

DEVON 

AYE- 
SHIRE 

3.89 

HOL- 

STEIN 
FRESIAN 

3.2 

JERSEY 

BROWN 

SWISS 

com' ON 
NATIVE 

Fat    

4.04 

4.09 

5.22 

4.0 

3.69 

Sugar    

4.34 

4.32 

4.41 

4.33 

4.84 

4.30 

4.35 

Proteid      

4.17 

4.04 

4.01 

3.99 

3.58 

4.00 

4.09 

Mineral    matter 

0.73 

0.73 

0.73 

0.74 

0.73 

0.76 

0.76 

Leach  gives  the  following  analysis  showing  the  composition  of 
milk  of  the  human  and  a  number  of  different  animals : 


340 


PRACTICALf   SANITATION. 


800 


200 


200 


32 


KIND 
OP    MILK 


Cow's  milk : 
Minimum    .  . 
Maximum   . . 

Mean   

Human  milk 
Minimum  .  . 
Maximum 

j\Iean    

Goat's  milk: 
Minimum  .  . 
Maximum  .  . 
Mean  ..... 
Ewe's  Milk: 
Minimum  .  . 
Maximum     . 

Mean     

Mare's  milk : 

Mean    

Ass's  milk : 
Mean    


SPE- 
CIFIC 
GRAVITY 

WATER 

CASE- 
IN 

ALBU- 
MIN 

TOTAL 
TEIDS 

PEO- 

FAT 

MILK 
SUGAR 

1.0264 

80.32 

1.79 

0.25 

2.07 

1.67 

2.11 

1.0370 

90.32 

6.29 

1.44 

6.40 

6.47 

6.12 

1.0315 

87.27 

3.02 

0.53 

3.55 

3.64 

4.88 

1.027 

81.09 

0.18 

0.32 

0.69 

1.43 

3.88 

1.032 

91.40 

1.96 

2.36 

4.70 

6.83 

8.34 

— 

87.41 

1.03 

1,26 

.2.29 

3.78 

6.21 

1.0280 

82.02 

2.44 

0.78 



3.10 

3.26 

1.0360 

90.16 

3.94 

2.01 

— 

7.55 

5.77 

1.0305 

85.71 

3.20 

1.09 

4.29 

4.78 

4.46 

1.0298 

74.47 

3.59 

0.83 



2.81 

2.76 

1.0385 

87.02 

5.69 

1.77 

— 

9.80 

7.95 

1.0341 

80.82 

4.97 

1.55 

6.52 

6.86 

4.91 

1.0347 

90.78 

1.24 

0.75 

1.99 

1.21 

5.67 

1.036 

89.64 

0.67 

1.55 

2.22 

1.64 

5.99 

0.35 
1.21 
0.71 

0.12 
1.90 
0.31 

0.39 
1.06 
0.76 

0.13 

1.72 
0.80 

0.35 

0.51 


Analysis  of  Milk. 

Milk  Supply  and  Infant  Mortality.— The  quality  of  the  milk 
supply  of  a  community  stands  in  such  close  relation  to  the  rate  of 
infant  mortality  that  every  health  officer  should  have  a  definite 
understanding  of  what  is  required  in  the  production  and  delivery 
of  clean  milk.  Bacteria  are  so  ubiquitous  and  milk  is  such  an 
excellent  culture  medium  for  their  growth  that  it  is  necessary  to 
watch  every  event  in  the  ''long  haul"  from  the  cow  to  the  con- 
sumer in  order  to  detect  the  source  of  any  contamination  that  may 
occur. 

Inspections. — To  determine  the  quality  of  a  given  milk  supply 
it  is  necessary  to  make  a  thorough  sanitary  survey  of  the  dairy 
barn,  the  bottling  establishment  and  the  method  of  transmission 
from  the  dairy  to  the  consumer,  as  well  as  to  make  bacteriological 
and  chemical  analysis  of  samples  of  the  milk  itself.  The  most 
rigid  control  of  dairies  is  not  sufficient  to  insure  a  pure  milk  to  the 
consumer,  inasmuch  as  the  product  may  become  grossly  contami- 


MILK.  341 

nated  from  improper  handling  by  middle  men.  These  sanitary 
features  are  beyond  the  purpose  of  this  chapter  which  must  be 
limited  to  a  discussion  on  the  part  the  laboratory  can  play  in  de- 
tecting evidences  of  impurities  in  milk. 

Milk  Samples. — A  sample  of  milk  for  either  bacteriological  or 
chemical  examination  should  be  taken  as  nearly  as  possible  in  the 
way  in  which  it  is  received  by  the  consumer. 

If  it  is  sold  in  bottles,  an  unopened  bottle  should  be  taken.  If 
sold  in  bulk,  it  should  be  obtained  in  a  wide-mouthed  sterile  bottle 
after  first  thoroughly  stirring  the  milk  in  the  container.  Bottles 
similar  to  those  used  for  samples  of  water  are  suitable  for  this 
purpose.  If  the  sample  cannot  be  examined  in  less  than  an  hour 
it  should  be  kept  packed  in  ice  until  the  examination  can  be  made. 
If  milk  is  kept  at  room  temperature  for  2  or  3  hours,  the  number 
of  bacteria  will  have  enormously  increased,  and  the  proportions 
of  the  various  kinds  of  organisms  present  may  be  completely 
changed. 

"If  milk  from  individual  cows  is  being  collected,  the  teats  and 
the  milker's  hands  should  be  washed  or  disinfected.  In  some 
cases  it  is  necessary  to  collect  a  separate  sample  from  each  quarter 
of  the  udder,  while  for  a  complete  examination  fore,  middle  and 
end  milk  samples  should  be  collected."     (Kenweed.) 

The  bacteriological  and  microscopical  examination  of  milk  is  util- 
ized to  determine  the  general  bacterial  content  of  the  milk,  especially 
the  degree  of  contamination  with  fecal  matter ;  to  discover  whether 
certain  pathogenic  organisms,  such  as  B.  tuberculosis,  are  present; 
and  to  determine  the  healthiness  of  the  udder  of  the  cow. 

Bacteriological  Examinations. — The  bacterial  content  of  milk, 
both  quantitative  and  qualitative  is  ascertained  by  methods  exactly 
similar  to  those  used  in  bacteriological  analysis  of  water.  Fermen- 
tation tubes  are  inoculated  with  fractional  parts  of  a  cubic  centi- 
meter of  milk  to  determine  the  presence  of  B.  Goli  and  the  approxi- 
mate number  of  these  organisms.  Agar  and  gelatin  plates  are 
inoculated  with  dilutions  of  the  milk  and  the  total  number  of 
bacteria  per  cubic  centimeter  ascertained  by  counting  the  colonies 
developing  on  the  plates. 

Bacteriological  Standards. — The  bacteriological  standards  for 
milk  vary  in  different  cities.  A  few  years  ago  the  average  bacterial 
counts  obtained  in  the  milk  of  most  cities  was  very  high,  ranging 
from  2,300,000  bacteria  per  cubic  centimeter  of  milk  in  Boston  to 


342 


PRACTICAL   SANITATION. 


7,000,000  bacteria  per  cubic  centimeter  in  the  milk  sold  in  Wil- 
mington, Delaware.  As  a  result  of  numerous  bacteriological  ex- 
aminations and  public  agitation  the  milk  situation  in  all  the  large 
cities  of  the  country  has  greatly  improved.  In  the  smaller  towns 
and  villages  where  there  is  no  pretense  of  sanitary  control  of  the 
milk  supply,  conditions  are  still  exceedingly  bad,  much  worse,  no 
doubt,  than  conditions  in  "Wilmington,  Delaware,  several  years  ago. 
There  is  no  universally^  recognized  standard  for  the  maximum 
bacterial  content  allowable  in  milk.  It  would  be  well,  however,  for 
"health  officers  to  aim  to  keep  the  general  milk  supply  below  the 


Pig.   36. — A  sample  of   the  unsuspected  but   dangerous  tubercular   cow. 

veterinarian   after   test. 


Rejected  by   the 


100,000  mark."  For  infant  feeding,  10,000  bacteria  per  cubic 
centimeter  should  be  the  maximum. 

The  discovery  of  pathogenic  bacteria  in  milk  is  a  matter  of  great 
difficulty  and  negative  results  have  practically  no  value.  Typhoid 
and  diphtheria  bacilli  have  been  found  in  milk,  but  only  on  ex- 
tremely rare  occasions.  The  search  for  tubercle  bacilli  is  more  often 
successful.  This  is  accomplished  by  means  of  centrifuging  large 
amounts  of  milk,  up  to  one  pint,  and  injecting  the  sediment  into  a 
guinea-pig.  If  tubercule  bacilli  are  present  in  the  milk  the  animal 
will  usually  succumb  to  tuberculosis  in  six  to  eight  weeks.  If  the 
animal  does  not  die  in  this  time  it  is  either  killed  and  examined 
post  mortem,  or  injected  with  tuberculin  which  will  reveal  the 
existence  of  a  non-fatal  tuberculous  process. 

Tubercle  Bacilli. — In  regard  to  the  presence  of  tubercle  bacilli 
in  milk,  recent  investigations  have  shown  that  cattle  which  react  to 


MILK. 


343 


tuberculin  do  not  necessarily  throw  off  tubercle  bacilli  until  the 
development  of  ''open"  lesions;  that  milk  from  cows  with  "open" 
lesions  of  the  respiratory,  alimentary  or  genito-urinary  tracts  is 
usually  found  to  be  accidentally  infected  with  tubercle  bacilli ;  and 
that  milk  from  cows  with  tuberculous  udders  is  always  infected. 

Milk  and  Epidemics. — That  milk  has  been  the  carrier  of  in- 
fection in  a  large  number  of  epidemics  has  been  frequently  proved 
by  circumstantial  evidence  and,  in  a  few  rare  instances,  by  direct 
evidence.     In  1909,  Trask  was  able  to  collect  from  the  literature 


A 

37. — Sanitiirj^  milk  pails.  A,  Gurler  milk  pail.  Gauze  fits  over  opening  with  layer 
of   cotton   between.      B,   Hooded  milk  pail. 

The  milk  pail  should  be  so  con.structed  as  to  be  easily  cleaned.  The  cover  should 
be  so  convex  as  to  make  the  entire  interior  of  the  pail  visible  and  accessible  for 
cleaning.  The  chief  aim  being  to  keep  dirt  out  of  milk,  and  as  much  comes  from 
the  cow's  skin  and  tail,  the  buckets  which  have  a  small  opening  at  the  top  and 
more  at  the  side  than  in  the  middle,  allow  the  milk  to  be  drawn  into  it  easily  and 
prevent  the  dirt  and  hair  dropping  into  it. 

The  pail  should  be  made  of  heavy  seamless  tin,  and  with  seams  which  are  iiushed 
and  made  smooth  by  solder.  Wooden  pails,  galvanized-iron  pails,  or  pails  made 
of  rough,  porous  materials,  are  forbidden.  All  utensils  used  in  milking  should  be 
kept  in  good  repair. 


reports  of  317  epidemics  of  typhoid  fever  (including  reports  of 
138  epidemics  previously  collected  by  Busey  and  Kober),  51  epi- 
demics of  scarlet  fever,  and  23  epidemics  of  diphtheria  that  were 
traceable  to  milk.  Park. and  Krumwiede  have  analyzed  1038  cases 
of  tuberculosis  in  which  the  type  of  infecting  organism  was  posi- 
tively determined  and  conclude  that  ' '  the  evidence  of  bovine  tuber- 
culosis is  practically  a  negligible  factor  in  adult  tuberculosis.  In 
children,  however,  it  causes  a  considerable  percentage  of  cervical 
adenitis  requiring  operative  interference ;  in  young  children  an 


344  PRACTICAL   SANITATION. 

appreciable  amount  of  fatal  tuberculosis  is  caused  by  such  infec- 
tion." 

Leucocytes. — Milk  normally  contains  leucocytes.  The  number 
present  in  the  milk  of  perfectly  healthy  cows  varies  not  only  with 
the  individual  cow,  but  also  with  the  same  animal  at  different 
times.  It  is  very  difficult  to  determine  the  dividing  line  which 
will  enable  one  to  say  that  this  milk  contains  only  normal  leucocytes 
and  that  contains  pus.  If,  in  the  judgment  of  the  bacteriologist, 
a  given  sample  of  milk  contains  pus  the  use  of  the  milk  should  be 
at  once  discontinued.  If  the  sample  was  composed  of  the  mixed 
milk  of  a  herd,  it  will  only  be  necessary  to  discover  and  exclude 
the  offending  cows. 

Visible  Dirt. — The  presence  of  visible  dirt  in  milk  is  sufficient 
in  some  states  to  condemn  it  without  the  necessity  of  determining 
its  exact  character  and  source.  Examined  microscopically  the 
"dirt"  may  show  black  and  brown  masses  of  amorphous  material, 
vegetable  cells,  masses  of  cellulose,  vascular  spirals  from  plants, 
hairs,  textile  fibers,  etc.  The  presence  of  masses  of  vegetable  cells 
and  vascular  spirals  from  plants  furnishes  strong  evidence  of  fecal 
contamination. 


CHAPTER  XXXVII. 
WATER. 

WATER  ANALYSIS. 

Sanitary  analysis  of  water  is  undertaken  to  "gauge  its  freedom 
from  organic  contamination,  and  to  estimate  its  suitability  for 
drinking  purposes."  Such  an  analysis  involves  a  sanitary  survey 
of  the  source  of  the  supply,  and  bacteriological  and  chemical  ex- 
aminations of  samples  of  the  water  itself.  Consideration  of  all  the 
facts  obtained  from  all  three  sources  is  essential  to  the  determina- 
tion of  the  safety  of  a  given  water  for  drinking  purposes.  ''In 
sanitary  water  analysis  the  factors  involved  are  so  complex  and 
the  evidence  necessarily  so  indirect  that  the  process  of  reasoning 
much  more  resembles  a  doctor's  diagnosis  than  an  engineering 
test."     (Prescott  &  Winslow.) 

Complete  Survey  Necessary. — A  health  officer  can  make  no  more 
grievous  mistake  in  the  presence  of  an  epidemic  of  typhoid  fever 
or  dysentery  than  to  rely  upon  a  single  bacteriological  or  chemical 
analysis  of  the  water  supply  to  reveal  the  source  of  the  infection. 
In  such  a  case  a  careful  survey  of  the  situation  as  a  whole  should 
be  made  before  submitting  any  kind  of  sample  for  laboratory  ex- 
amination. It  should  be  remembered  that  by  the  time  the  effects 
of  pollution  show  themselves  in  the  form  of  illness  in  the  users  of 
the  water,  the  source  of  the  pollution  may  have  entirely  disap- 
peared. 

How  unreliable  a  single  examination  of  water  may  be  is  shown 
by  the  following  occurrence.  In  April,  1910,  an  epidemic  of 
typhoid  fever  broke  out  in  one  of  the  state  institutions  of  Indiana. 
The  officers  and  their  families  as  well  as  the  inmates  were  affected. 
A  careful  survey  of  the  whole  situation  pointed  either  to  milk  or 
water  as  the  source  of  the  infection  inasmuch  as  these  were  the  only 
things  used  in  common  by  the  officers  and  their  families  and  the 
inmates.  A  bacteriological  examination  of  the  institution's  water 
supply,  which  came  from  a  large  spring  on  the  grounds,  on  April 
29,  showed  nothing  in  the  least  suspicious.     A  sample  taken  later 

345 


346  PRACTICAL   SANITATION. 

in  the  afternoon  of  ]\Iay  2,  gave  a  presumptive  test  for  B.  Coli. 
Another  sample  on  ]\Iay  7,  proved  to  be  excellent  so  far  as  bacteri- 
ological examination  was  concerned.  It  was  then  learned  that  on 
the  morning  of  May  2,  the  sewers  of  the  institution  had  been 
flushed  out  under  considerable  pressure.  On  May  20,  samples  of 
water  taken  at  6  :00  a.  m.  and  6 :00  p.  m.  showed  no  evidence  of 
contamination.  The  sewers  were  flushed  shortly  before  noon  on 
the  same  day.  A  sample  of  water  taken  at  6 :00  a.  m.  May  21, 
showed  such  abundant  pollution  that  B.  Coli  was  isolated  from  the 
water  and  identified  in  cultures.  It  was  learned  afterward  that 
about  two  weeks  before  the  outbreak  of  the  epidemic  the  sewers 
had  been  flushed  for  the  first  time  in  more  than  a  year. 

Survey  Msthods. — Whether  the  supply  is  local,  from  a  single 
spring  or  well  or  involves  a  large  area  of  watershed  for  a  municipal 
supply,  the  methods  of  survey  are  identical. 

Surface  Topograppiy. — The  first  thing  to  consider  is  the  topog- 
raphy of  the  land,  for  it  is  obviously  useless  to  extend  the  survey 
downhill  from  a  spring  or  on  the  other  side  of  the  watershed  in  a 
public  supply.  If  in  doubt  as  to  whether  the  area  should  properly 
be  included,  a  bucketful  of  water  poured  on  the  ground  will  gen- 
erally be  enough  to  show  whether  the  flow  is  toward  or  away  from 
the  supply  under  investigation. 

Geology. — The  geology  of  the  tract  will  greatly  influence  the 
water  supply.  Light  sandy  soils  offer  little  obstacle  to  the  rapid  pas- 
sage of  water,  and  limestone  is  full  of  fissures  which  may  lead  from 
a  cesspool  to  a  spring  or  well  at  a  considerable  distance  and  permit 
the  passage  of  practically  unchanged  sewage.  On  the  other  hand 
massive  shales  and  the  igneous  rocks  are  practically  impervious  to 
watCT  and  sandstone  while  it  allows  it  to  pass,  filters  it  and  usually 
makes  it  safe. 

Sources  of  Pollution. — The  most  dangerous  form  of  pollution 
which  is  found  in  water  is  human  excreta,  and  the  area  under  ex- 
amination should  be  carefully  scanned  for  sewers,  priiies  and  cesF- 
pools.  Next  to  this  is  animal  excreta  and  the  presence  of  harujjards, 
pifj-slies  and  the  like  should  be  noted.  So  far  as  possible  all  per- 
manent human  habitations  should  be  cleared  from  nmnicipal  water- 
sheds although  their  use  for  agriculture  or  pasture  is  not  so  objec- 
tionable. 

Maps. — No  survey  is  complete  till  it  is  mai)pod.  The  map  may  be 
the  rough  sketch  of  an  amateur  or  the  finished  contour  map  of  the 


WATER.  347 

skilled  surveyor,  but  it  should  be  made  to  accompany  the  notes. 
Dwellings,  barns,  privies,  sewers  and  so  on  may  readily  be  indicated 
by  convejilional  signs.  Small  forms  such  as  are  suggested  on  page 
25  for  epidemiological  work  may  also  be  used  conveniently  in  cities 
and  towns. 

Bacteriological  Water  Analysis. 

Bacteriological  analysis  of  w^ater  is  both  quantitative  and  qualita- 
tive. Quantitative  estimations  show  the  total  number  of  bacteria 
which  are  cajiable  of  growing  on  artificial  culture  media.  Daily  or 
weekly  quantitative  estimations  will  determine  the  normal  bacterial 
content  of  a  given  water  supply  and  will  reveal  any  unusual 
variation  from  this  normal  content.  Qualitative  examinations  ' '  de- 
termine the  nature  of  the  organisms,  and  especially  whether  they 
are  such  as  to  be  found  in  excreta  from  the  body,"  that  is,  they 
reveal  potential  and  in  rare  instances  actual  danger. 

It  is  not  intended  that  this  chapter  serve  as  a  laboratory  guide. 
Only  those  facts  concerning  bacteriological  and  chemical  analysis 
will  be  given  which  concern  the  health  officer  on  the  field,  such  as 
the  manner  of  collecting  and  preparing  samples  and  the  interpreta- 
tion of  results  as  reported  from  the  laboratory.  Laboratory 
methods  will  be  referred  to  only  in  so  far  as  they  will  aid  the 
health  officer  in  understanding  results. 

Samples: — Bacteria  are  everywhere  present,  hence  the  most 
rigid  precautions  are  necessary  in  taking  a  sample  of  water  for 
bacteriological  examination  to  avoid  the  introduction  of  extraneous 
organisms.  Obviously,  a  bacteriological  analysis  of  a  sample  of 
water  taken  in  any  but  an  absolutely  sterile  container  will  be  worse 
than  worthless.  Sterile  bottles  holding  at  least  100  c.c.  and  having 
ground  glass  stoppers  are  furnished  by  laboratories  for  collecting 
specimens  of  water.     These  alone  should  be  used  for.  this  purpose. 

If  the  sample  is  to  be  taken  from  a  stream  or  lake,  the  bottle 
should  be  pushed  beneath  the  surface  to  a  sufficient  depth  to  avoid 
surface  contaminations  before  removing  the  stopper.  If  taken 
from  a  pump,  sufficient  water  should  be  pumped  out  to  at  least 
avoid  water  that  has  been  standing  in  the  pipes.  If  the  sample  is 
from  a  hydrant  allow  the  water  to  run  for  10  or  15  minutes  before 
filling  the  bottle.  In  other  words,  "the  water  should  always  be 
collected  for  analysis  just  as  it  is  ordinarily  obtained  for  drinking 
purposes. ' ' 


348  PRACTICAL    SANITATION. 

If  the  water  cannot  be  examined  at  once  it  should  be  packed  in 
ice  until  it  reaches  the  laboratory.  Public  health  laboratories,  as 
a  rule,  furnish  outfits  for  collecting  and  transmitting  specimens 
of  water  for  bacteriological  examination.  These  are  arranged  for 
refrigerating  the  samples  during  transit  and  these  outfits  alone 
should  be  used  in  sending  specimens  to  laboratories. 

Information  to  Accompany  Sample. — Along  with  the  sample  cer- 
tain definite  information  should  be  sent.  This  is  necessary  to  a 
proper  interpretation  of  the  results  of  the  examination.  The 
following  facts  concerning  each  specimen  should  be  stated: 
Name  and  address  of  the  sender;  reason  for  the  analysis; 
source  of  the  sample;  place,  date  and  hour  of  collection; 
character  of  the  soil  and  subsoil  of  the  district ;  rainfall  during  the 
previous  week ;  nature  and  distance  of  any  evident  or  possible  source 
of  pollution;  any  cases  of  sickness  among  the  users  of  the  water 
that  east  suspicion  upon  it  as  the  source  of  infection,  etc. 

Examination  in  Laboratory. — "When  the  sample  reaches  the 
laboratory,  dilutions  of  the  water  of  1  to  100,  1  to  1000,  etc.,  are 
made  in  sterile  water.  One  cubic  centimeter  of  the  dilution  is 
placed  in  each  of  several  Petri  dishes.  Cooled,  melted  agar-agar 
or  cooled  melted  gelatin  is  poured  into  the  dish,  thoroughly  mixed 
with  the  water  and  allowed  to  harden.  The  total  number  of  colonies 
of  bacteria  developing  on  a  plate  after  24  to  48  hours,  multiplied  by 
the  dilution  gives  the  total  number  of  bacteria  in  a  cubic  centimeter 
of  the  original  water. 

It  should  be  distinctly  borne  in  mind  that  all  quantitative  esti- 
mations of  the  number  of  bacteria  in  a  sample  of  water  are  approxi- 
mate only.  In  the  first  place,  it  is  practically  impossible  to  get  a 
single  sample,  especially  from  a  large  body  of  water,  that  will 
represent  a  fair  average  of  the  whole.  Furthermore,  many  bacteria 
formed  in  water  will  not  grow  at  incubator  temperature.  Finally, 
quite  marked  changes  in  the  bacterial  content  of  a  sample  of  water 
will  occur  in  transit  even  though  it  be  packed  in  ice.  If  the  sample 
is  not  packed  in  ice  these  changes  become  so  great  as  to  entirely 
vitiate  the  results  of  a  quantitative  bacteriological  estimation. 
There  is,  therefore,  no  recognized  standard  of  safety  for  water  based 
upon  quantitative  bacteriologic  examination.  For  after  all,  the 
kind  of  bacteria  present  in  a  water  is  more  important  than  the 
number. 

Qualitative  Bacteriological  Examination. — The  kinds  of  bacteria 


WATER.  349 

present  are  determined  by  qualitative  examinations.  These  con- 
sist in  determining  either  by  presumptive  tests  or  by  actual  isolation 
and  identification,  the  presence  of  bacteria  not  necessarily  harmful 
in  themselves  (e.g.,  B.  Coli),  but  which  on  account  of  their  origin 
are  especially  likely  to  be  associated  with  bacteria  that  are  patho- 
genic. In  very  rare  instances  the  pathogenic  bacteria  {B.  typhosus 
or  Vibrio  cholercB)  have  been  isolated  from  water.  This  is  a  feat 
so  rare  of  accomplishment,  however,  that  no  bacteriologist  makes 
such  an  examination  as  a  matter  of  routine. 

"Coli"  Test.- — The  presumptive  test  for  B.  Coli  is  carried  out 
by  means  of  inoculating  fermentation  tubes  of  dextrose  or  lactose 
broth  (with  or  without  litmus  or  neutral  red),  with  amounts  of  the 
water  ranging  from  0.001  of  a  cubic  centimeter  to  1  e.c.  The 
presence  of  gas  in  any  of  the  tubes  is  taken  to  indicate  the  presence 
of  B.  Coli,  and  the  number  of  colon  bacilli  per  cubic  centimeter 
of  water  can  be  roughly  estimated  from  the  smallest  quantity  that 
will  cause  the  production  of  gas. 

In  some  laboratories  the  water  is  inoculated  into  special  ' '  enrich- 
ment media"  which  favor  the  development  of  B.  Coli.  After  in- 
cubation, cultures  are  made  from  the  special  media  on  some  of  the 
different  plate  media,  such  as  Endo's.  In  this  way,  a  skillful  bac- 
teriologist is  very  frequently  able  to  pick  off  and  positively  identify 
colon  bacilli.  This  method  of  isolation  and  identification  of  B.  Coli 
from  samples  of  water  is  now  carried  out  as  a  matter  of  routine 
in  many  laboratories. 

On  the  value  of  the  colon  test  there  is  still  difference  of  opinion. 
The  mere  presence  of  this  organism  in  water  is  not  absolute  proof 
of  pollution  with  human  excreta,  for  these  same  organisms  are  also 
found  in  the  intestines  of  domestic  animals.  From  the  public  health 
point  of  view  it  is  safe,  however,  to  conclude  that  the  presence  of 
colon  bacilli  in  water  in  considerable  numbers  always  points  to 
sewage  contamination ;  even  waters  with  one  colon  bacillus  in  10  e.c. 
should  be  regarded  as  suspicious.  The  absence  of  B.  Coli,  especially 
if  ' '  enrichment  media ' '  are  used,  is  a  reliable  index  of  purity  of  the 
water. 

Chemical  Analysis  of  Water. 

At  least  1  gallon  of  water  is  necessary  for  complete  chemical 
analysis.  This  should  be  sent  in  a  large  protected  bottle  or  demi- 
john which  has  been  carefully  cleansed.     A  specimen  for  chemical 


350  PRACTICAL   SANITATION. 

analysis  should  never  be  sent  in  a  stone  jug,  tin  can,  or  wooden 
vessel.  Before  filling  the  bottle  it  should  be  rinsed  with  some  of 
the  water  that  is  to  be  sent  for  examination.  It  is  necessary,  also, 
that  information  on  the  same  points  mentioned  under  Bacteriological 
Water  Analysis  accompany  the  specimen.  A  chemical  finding  which 
is  quite  normal  in  one  locality  may  be  evidence  of  pollution  in  an- 
other. The  substances  examined  for  in  chemical  analysis  of  water 
are  free  ammonia,  albuminoid  ammonia,  nitrogen  as  nitrates  and 
nitrites,  and  chlorine. 

Free  ammonia  is  present  in  rain  water  and  is  of  no  significane© 
there.  In  subsoil  waters,  its  importance  depends  much  upon  asSo^ 
ciated  compounds.  If  found  alone  it  has  little  or  no  sanitary  signifi- 
cance. If  associated  with  a  considerable  amount  of  chlorine,  it 
usually  indicates  pollution  with  urine,  the  urea  of  which  has  under- 
gone ammoniacal  decomposition.  High  free  ammonia  with  high 
albuminoid  ammonia,  chlorine  and  oxidized  nitrogen  (nitrates  or 
nitrites)  denote  animal  pollution. 

Albuminoid  ammonia  alone  or  with  mere  traces  of  free  ammonia 
indicates  vegetable  contamination. 

The  importance  of  chlorine  in  water  depends  very  largely  upon 
the  source  of  the  sample.  If  taken  from  a  well  on  the  seacoast  or 
from  soil  known  to  be  rich  in  chlorides,  it  is  of  no  sanitary  signifi- 
cance. In  an  ordinary  inland  well,  an  excess  of  chlorine  indicates 
pollution  with  household  slops  or  sewage. 

The  presence  of  nitrates  and  nitrites  in  water  is  practically  posi- 
tive evidence  of  pollution.  Nitrates  indicate  potentially  dangerous 
bacterial  pollution  at  some  past  time ;  the  water  may  or  may  not  be 
dangerous  at  the  time  the  sample  is  taken.  Nitrites  denote  the  same 
bacterial  activity  in  process  of  accomplishment  and  are  therefore 
always  danger  signals. 

There  are  no  recognized  chemical  standards  by  which  a  water  can 
be  unqualifiedly  condemned  or  passed  as  pure.  The  following 
table,  modified  from  Harrington,  indicates  the  proportion  of 
chemical  substances  actually  found  in  samples  of  waters  known  to 
be  good  and  bad  respectively : 


WATER. 


351 


Parts  per  100,000 

Parts  per  100,000 

IN  A  GOOD  WATER 

IN    A    BAD    water 

Froe  iiiiiiiiouia   

0.0002 

0.0018 

0.4750 

Albimiinoid  Ammonia 

0.0585 

Nitrogen  as  nitrates   

0.0240 

4.6000 

Nitrogen  as  nitrites    

0.0000 

0.0540 

Chlorine                 

0.07 
1.25 
l.GO 

4.27 

Volatile  residue   

11.10 

Fixed  residue   

23.30 

Total  residue 

2.85 

34.40 

Hardness    

1.00 
Clear  and  briglit 

14.00 

Appearance 

Clear  and  bright 

Color 

Absent 

Absent 

Odor 

Absent 

Foul  after  boiling 

Changes  on  ignition  of  residue 

No  blackening 

Slight  blackening 

Purificj-tion  of  Municipal  Supplies. — Very  few  surface  supplies 
except  those  arising'  in  totally  uninhabited  country  are  free  from 
suspicion.  For  those  cities  which  cannot  develop  such  a  supply  or 
one  from  deep  wells,  some  form  of  purification  is  consequently  nec- 
essary. These  are  storage,  filtration,  and  chemical  treatment. 
Scarcely  any  two  water  supplies  require  identical  treatment,  so  that 
expert  advice  should  always  be  secured  before  installing  a  purifica- 
tion plant. 

Storage  is  efficient  to  a  considerable  degree  in  the  destruction  of 
pathogenic  germs,  because  the  settling  out  of  turbidity  permits  the 
action  of  solar  light  upon  them.  Possibly  more  important  is  the 
overgrowth  of  non-pathogenic  water  bacteria  which  kill  out  the 
harmful  forms. 

Filtration. — Filters  are  of  many  kinds  and  patterns.  Sand  is  the 
material  most  used  but  it  is  not  the  real  filtering  material.  Under 
use  a  sand  filter  becomes  covered  with  a  fine  pellicle  composed 
partly  of  mineral  and  partly  of  organic  matter  which  prevents  the 
passage  of  a  great  part  of  the  bacteria.  Filters  may  be  slow,  de- 
pending only  on  gravity  acting  through  a  low  head  of  water  or  rapid, 
in  which  the  water  is  forced  or  pumped  through.  They  are  usually 
preceded  by  settling  basins  which  allow  the  grosser  sediment  to  de- 
posit. At  this  point  a  coagulant  such  as  aluminum  sulphate,  1  to  5 
grains  to  the  gallon,  with  or  without  a  proper  equivalent  of  soda  ash 
may  be  introduced.  This  coagulates  the  colloidal  clay  or  silica 
present  as  well  as  many  of  the  bacteria  and  throws  them  down  in 
the  settling  basin.     From  this  point,  the  water  goes  through  one  or 


352 


PRACTICAL   SANITATION. 


Webber  bcc»rind  drcveK^  _f-T 


-Ol.     -  —f-i. 


Pig.  38. — Surface  contamination. 


Privy  Driven  well 


Fig.  39. — Contamination  \>y  percolation. 


Pig.  40. — Contamination  through  crevices. 


WATER.  353 

more  filters  and  the  effluent  is  then  treated  with  calcium  hypo- 
chJorite  or  chlorine  gas,  1  to  II/2  parts  per  million.  A  water  so 
treated,  if  the  work  is  carefully  done,  is  always  safe,  even  in  the 
face  of  serious  initial  pollution. 


CHAPTER  XXXVIIl. 

NUISANCES. 

Definition. — The  subject  of  nuisances  is  one  which  plays  a  large 
part  in  the  daily  work  of  the  health  officer,  but  is  from  a  sanitary 
point  of  view  of  comparatively  small  importance.  A  nuisance  is 
primaril}^  anything  which  is  offensive  to  the  senses,  noxious  to 
health,  or  interferes  with  the  convenience  of  the  public.  The  latter 
class,  which  consists  of  such  offenses  as  damming  and  diversion  of 
streams  or  water-flows,  and  fencing  of  public  grounds  or  roads, 
may  be  dismissed  at  once  as  not  nuisances  in  the  sanitary  sense, 
although  legally  classified  as  such.  In  order  that  the  idea  of 
nuisance  in  law  may  be  understood,  the  section  of  the  Indiana 
statute  defining  it  is  appended  in  full  to  this  chapter,  which  defi- 
nition is  very  typical  of  the  statutes  of  all  the  states. 

Necessity  for  Investigation. — The  class  of  cases  in  which  the 
health  officer  is  most  of  ten  asked  to  use  his  authority  is  that  in  which 
"noxious  exhalations,  or  noisome  or  offensive  smells  become  injuri- 
ous to  the  health,  comfort  or  property  of  individuals  or  the  public" 
or  "offal,  filth  or  noisome  substance  is  collected  or  remains  in  any 
place  to  the  damage,  discomfort  or  prejudice  of  the  public."  Very 
frequently  indeed  it  will  be  found  that  attempts  are  made  to  "get 
even"  in  neighborhood  quarrels  through  the  medium  of  the  health 
officer.  Nevertheless,  it  often  occurs  that  real  nuisances  of  a  kind 
that  may  well  be  injurious  to  health,  as  filthy  slaughterhouses,  over- 
flowing privies  or  dead  animals  are  to  be  found,  so  that  every  case 
must  be  investigated  and  decided  on  its  merits.  But  before  the 
health  officer  issues  his  order  for  the  abatement  of  the  alleged 
nuisance,  he  must  be  absolutely  sure  that  the  matter  really  does 
concern  either  the  health  of  the  public  or  of  some  individual,  other- 
wise he  is  intermeddling  with  what  does  not  concern  him.  If  he 
believes  that  the  nuisance  is  real,  but  does  not  concern  the  public 
health,  he  should  refer  the  complainant  to  the  prosecuting  attorney 
for  relief.    If  he  believes  that  the  matter  does  tend  to  create  sick- 

354 


NUISANCES. 


355 


Fig.  41. — This  open  ditch  is  full  of  sewage  and  men 


iiby  private  water  supplies. 


Fig'.    42. — A   sanitarr   crime. 


ness,  it  is  then  his  duty  to  act  with  vigor  by  issuing  the  order 
for  abatement  and  if  necessary  prosecuting  the  offender. 

Sanitary  Nuisances. — Nuisances  really  injurious  to  the  public 
health  are  comparatively  few.  Accumulations  of  filth  which  pro- 
vide breeding  places  for  flies;  dead  animals  which  nauseate  the 
passer-by;  chimneys  giving  off  volumes  of  smoke  charged  with 
carbon  and  sulphurous  gases;  smelters  with  their  fumes  of  arsenic, 
sulphur,  tellurium  and  zinc  vapors;  privies  and  cesspools  whose 


356 


PRACTICAL   SANITATION. 


foul  coutents  are  likely  to  be  transferred  by  flies  to  someone's 
dinner-table;  manure-piles  and  filthy  barns;  filthy  garbage  cans 
and  accumulations  of  kitchen  refuse,  are  almost  all  of  the  nuisances 
which  can  properly  be  said  to  be  injurious  to  the  public  health. 
Gas-works,  with  their  odors  of  ammonia  and  aniline,  glue  and 
fertilizer  factories,  tanneries  and  oil  refineries  may  be  nuisances 
at  law,  but  their  odors  are  hardly  prejudicial  to  health. 


Fig.  43. — An  effective  method  of  polluting  the  water  suppl.v. 

The  legal  idea  is  that  the  smell  is  in  itself  harmful,  but  this 
cannot  well  be  except  in  the  case  of  the  smelter  fumes  and  sulphur 
laden  coal  smoke  alluded  to  above.  The  ammoniacal  gases — hy- 
drogen sulphide  and  mercaptans,  arising  in  the  course  of  decom- 
position are  not  in  themselves  harmful  in  any  dosage  which  would 
be  likely  to  be  taken  through  inhalation,  but  the  flies  which  are 
bred  in  decomposing  substances  are  a  source  of  danger,  since  they 
may  carry  putrefactive  matters  and  inoculate  them  upon  persons  or 
food,  to  the  prejudice  of  the  public  health,  and  this  will  be  the  real 
reason  for  the  abatement  of  the  nuisance.     Similarly,  collections  of 


NUISANCES. 


357 


A  SANITARY  SURVEY 

or 

VINGENNES.  INDIANA. 


■   .•"7:-~P=^^;^.i^je-55-~j;*^$  - 


■  ■  ■■  Ip- 1 


"■'-'^s^ii^!:^-'?^-g-,    ~5wW 


Fi-r    44 — Showing   Incati m    of   privies    "iid    cesspoils    in    Vincennes.    India^^a.      (Prom    a 
Sanitary  Survey  made  by  the  Indiana   State  Board  of  Health  in  1914.) 

Heavy  dots  represent  privies,  light  dots  cesspools. 
Section    A   has    1175   privies   and    71   cesspools. 
B      "       824        "  "      53 

C       "       335        "  "      41 

D      "       895         "  "      22 


Total 3229 


187 


A  SANITARY  SURVEY 
VINCENNES.  INJIANA. 


Fi§.   45. — Shovi'ing   distribution  of   contaminated  vs'ells. 

Figs  44  and  45. — Note  the  correspondence  between  the 'privies  and  the  contaminated 
wells.  The  soil  is  principally  a  sandy  loam.  Each  dot  represents  a  polluted  private 
water    supply. 


358  ^        PRACTICAL   SANITATION. 

filth  which  are  likely  to  pollute  or  do  pollute  water  which  may  be 
used  for  domestic  or  stock  water,  constitute  genuine  nuisances,  but 
are  generally  prosecuted  under  a  separate  statute. 

The  health  officer  who  bears  clearly  in  mind  the  limitations  of  his 
authority  under  the  laws  of  his  particular  state  with  regard  to 
nuisances,  will  not  initiate  actions  without  due  cause  and  will  soon 
cease  to  be  sought  as  a  means  of  revenge,  while  the  one  who  does  not 
Avill  be  continually  involved  in  trivial  quarrels  to  the  detriment  of 
the  dignity  of  his  office  and  his  own  peace  of  mind. 

Sec.  215.'iA — Whoever  erects,  continues,  uses  or  maintains  any  building, 
structure  or  place  for  the  exercise  of  any  trade,  employment  or  business,  or 
for  the  keeping  and  feeding  of  any  animal,  which,  by  occasioning  noxious  in- 
halations or  noisome  or  offensive  smells,  becomes  injurious  to  the  health, 
comfort  or  property  of  individuals  or  the  public,  or  cause  or  suffer  any  offal, 
filth  or  noisome  substance  to  be  collected  or  to  remain  in  any  place,  to  the 
damage  or  prejudice  of  others  or  the  public,  or  obstructs  or  impedes,  without 
legal  authority,  the  passage  of  any  navigable  river,  harbor  or  collection  of 
waters,  or  unlawfully  diverts  any  stream  of  water  from  its  natural  course 
or  state  to  the  injury  of  others,  or  obstructs  or  encumbers  by  fences,  build- 
ing, structure  or  otherwise,  any  public  grounds,  or  erects,  continues  or  main- 
tains any  obstruction  to  the  full  use  of  property  so  as  to  injure  the  property 
of  another,  or  essentially  to  interfere  with  the  comfortable  enjoyment  of  life, 
shall  be  fined  not  more  than  five  hundred  dollars  nor  less  than  ten  dollars: 
Provided,  That  nothing  in  this  section  shall  prevent  the  Board  of  Trustees 
of  towns  and  the  Common  Council  of  cities  from  enacting  and  enforcing  such 
ordinances  within  their  respective  corporate  limits  as  they  may  deem  neces- 
sary to  protect  public  health  and  comfort. 


*  Burns'  Revised  Statutes,   1901. 


CHAPTEE  XXXIX. 
MISCELLANEOUS  SANITARY  LAWS. 

The  states  have  not  moved  with  equal  pace  in  the  enactment  of 
sanitary  laws,  and  some  are  in  advance  in  one  way,  some  in  another. 
Some  of  these  regulations  are  statutory  in  character,  some  are 
rules  of  State  Boards  of  Health,  and  some  are  in  force  in  certain 
states  under  one  guise,  and  in  other  states  under  the  other.  It 
will  be  sufficient  for  the  purposes  of  this  chapter  to  call  attention 
to  them,  leaving  the  searching  out  of  the  exact  form  in  which  they 
are  in  force  for  those  who  are  especially  interested  in  legislative 
work. 

Common  Drinking  Cups. — The  use  of  public  drinking  cups  is 
forbidden  by  law  in  Kansas,  Oklahoma,  Illinois,  Missouri  and  other 
states,  and  by  the  Public  Health  Service  to  all  transportation  com- 
panies engaged  in  Interstate  Commerce.  It  is  founded  on  the  well- 
known  fact  that  the  public  drinking  cup  is  an  ideal  means  for  the 
dissemination  of  the  diseases  which  particularly  affect  the  mucous 
membrane  of  the  throat  and  mouth,  as  syphilis,  tuberculosis,  pneu- 
monia, diphtheria,  and  the  exanthemata.  Wherever  it  is  forbidden 
to  use  public  drinking  cups,  a  trade  promptly  springs  up  in  the 
paraffined  paper  cups  sold  at  one  cent  each,  and  in  folding  metal 
cups.  Besides  its  directly  sanitary  features,  the  esthetic  side  of  the 
movement  is  not  to  be  neglected,  and  it  has  also  an  educational 
value  beyond  the  direct  and  immediate  results  obtained. 

Anti-Spitting  Ordinances. — Such  regulations  are  rarely  if  ever 
statutory,  but  depend  on  municipal  ordinances  or  orders  of  boards 
of  health,  state  or  local,  for  their  force.  They  forbid  spitting  on 
sidewalks,  gratings,  stairs,  halls,  in  street,  traction  or  railway  cars, 
and  other  public  places.  They  have  not  the  slightest  value  unless 
enforced,  and  unfortunately  they  are  rarely  enforced  at  all  times 
in  any  place.  The  sputum  may  convey  many  diseases  through  the 
agency  of  flies  which  carry  the  germs  to  food  or  drink,  and  a 
smaller  number  by  dust  infection.     Light  and  drying  have  a  tend- 

359 


360  PRACTICAL  SANITATION. 

ency  to  render  sputum  innocuous  after  a  time,  but  that  is  no  reason 

for  not  enforcing  all  regulations  of  this  character. 

Marriage  Laws. — Certain  of  the  states  have  adopted  laws  for- 
bidding the  marriage  of  the  insane,  feeble-minded,  epileptic,  tuber- 
cular and  syphilitic.  It  would  be  a  wise  thing  from  the  point  of 
state-craft  if  such  laws  were  in  force  everywhere,  but  unfortunately 
against  the  first  three  classes  named,  the  only  result  which  would 
be  likely,  is  an  increase  in  illegitimate  offspring.  Feeble-minded 
women  in  some  states  are  required  to  be  kept  isolated  in  institutions 
until  after  the  menopause,  and  the  same  rule  might  well  apply  to 
both  sexes  among,  the  insane  and  epileptic,  without  being  made 
absolute.     In  selected  cases  also,  the  following  statute  works  well. 

Sterilization  Law. — In  1907  the  legislature  of  Indiana  passed  a 
law  which  has  since  been  adopted  in  substance  by  a  number  of  states, 
under  which,  in  any  institution  in  the  state  entrusted  with  the  care 
of  ''confirmed  criminals,  idiots,  imbeciles  and  rapists"  a  board  of 
experts  consisting  of  the  institutional  physician  and  two  other  phy- 
sicians, acting  on  the  recommendation  of  the  institutional  board  of 
managers,  is  given  authority  to  perform  such  operation  for  the 
prevention  of  procreation  as  may  be  decided  safest  and  most  effec- 
tive, provided  that  they  shall  decide  that  the  person  is  unimprovable. 
This  is  a  wise  law,  and  worthy  of  much  wider  use  than  has  yet 
been  made  of  it.  The  ordinary  operation  done  by  its  authority  in 
the  male  is  vasectomy,  which  in  the  hands  of  an  expert  is  done  in  a 
few  minutes  time,  without  an  anesthetic  and  almost  without  pain, 
and  does  not  take  the  patient  away  from  his  work  for  more  than  a 
day.  By  its  authority,  in  the  case  of  those  guilty  of  rape  and  incest, 
castration  is  said  to  have  been  performed.  In  the  case  of  the  female, 
resection  of  the  oviducts  would  be  the  operation  of  choice.  As  this 
statute  is  in  no  sense  penal,  it  is  not  repugnant  to  the  section  of  the 
Constitution  of  the  United  States  which  forbids  cruel  and  unusual 
punishments. 


CHAPTER  XL. 
PUBLIC  EMERGENCIES. 

There  are  certain  sudden  calamities  which  strain  the  resources 
of  the  health  department  and  the  knowledge  and  ingenuity  of  its 
administrators  to  the  utmost.  These  are  fire,  flood,  earthquake  and 
explosion.  While  the  probability  of  any  one  of  these,  except  flood  in 
cities  and  villages  located  on  the  banks  of  streams,  is  small,  yet  their 
possibility  must  always  be  borne  in  mind  and  the  sanitarian  should 
have  a  clear  idea  of  what  he  can  do  to  mitigate  the  suffering  which 
they  always  carry  in  their  train. 

Fire. — This  presents  in  some  ways  the  easiest  problem  of  the  four. 
In  a  fire-swept  town  things  are  barren  and  desolate,  but  they  are  in 
a  sanitary  sense  clean.  The  principal  thing  to  be  done  is  to  secure 
food  and  shelter,  and  these  are  generally  sent  in  promptly  by  out- 
side agencies.  Incidental  difficulties  due  to  climate  will  be  noticed 
under  other  heads. 

Flood. — In  floods  we  have  a  much  more  difficult  condition  to  face. 
There  may  be  almost  as  much  destruction  of  property  as  by  fire  in 
floods  caused  by  the  rising  of  streams  and  in  those  caused  by  the 
breaking  of  dams  it  may  be  even  greater.  There  is  this  great  differ- 
ence, however — the  debris  of  a  flood  is  everywhere  in  the  flooded  dis- 
trict, and  this  consists  not  of  clean  ashes  and  cinders,  but  of  drift- 
wood, dead  animals,  mud  and  general  wreckage  which  must  be 
removed  at  once.  In  addition  cellars  and  basements  are  filled  with 
water  and  houses  are  soaked  with  muddy  water,  moved  from  their 
foundations  and  rendered  generally  uninhabitable.  To  make  mat- 
ters worse,  transportation  is  generally  interfered  with  by  the  wash- 
ing out  of  railroads  and  wagon  roads. 

Food  and  Shelter. — Before  these  can  be  brought  from  the  out- 
side, it  is  necessary  for  the  more  fortunately  situated  portion  of  the 
community  to  help  the  needy  fraction,  and  this  is  usually  done  un- 
grudgingly in  American  towns.  As  soon  as  conditions  have  im- 
proved sufficiently  to  permit  transportation  of  supplies,  whatever 
is  needed  will  be  sent  in  by  some  outside  relief  organization,  and 

361 


362  PRACTICAL   SANITATION. 

this  part  of  the  problem  will  ordinarily  give  no  trouble  to  the  health 
officer. 

Water  Supply. — It  is  rather  an  anomaly  that  tloods  should  pre- 
sent great  diffieulties  in  the  matter  of  water  supply,  but  such  is  the 
ease.  If  the  supply  is  from  a  stream  or  wells  situated  on  the  bank,  it 
is  almost  invariably  contaminated  with  flood  water,  which  is  charged 
not  only  with  nuul  but  with  surface  drainage.  Flood  waters  in  an 
iiihabited  country  carry  in  suspension  animal  and  human  excreta, 
vegetable  debris;  sand  and  mud,  besides  such  evident  contaminations 
as  dead  animals  and  rotting  vegetation.  Such  water  must  be  filtered 
and  treated  as  described  in  Chapter  XXXVIII,  or  else  allowed  to 
settle,  and  boiled.  Wells  used  only  for  domestic  supply  may  be 
cleaned  out  as  soon  as  the  tlood  subsides  and  the  water  treated  as 
above  till  analysis  shows  it  to  he  safe.  Cisterns  should  be  treated 
by  adding  the  necessary  amount  of  alum  (1  to  5  grains  per  gallon) 
to  precipitate  the  mud,  and  chloride  of  lime  added  to  the  amount  of 
1  or  2  grains  per  gallon.  The  precipitated  mud  can  be  taken  from 
the  bottom  without  disturbing  the  water  by  an  apparatus  made 
for  the  purpose.  It  goes  without  saying  that  any  water  can  be 
made  safe  by  boiling  for  20  minutes. 

Police. — The  "police"  or  cleaning  up  after  any  kind  of  calamity 
is  an  undertaking  which  must  be  pressed  with  all  possible  speed. 
With  the  dislocation  of  the  labor  market  which  always  attends  such 
happenings,  a  supply  of  labor  is  almost  always  at  hand  commensur- 
ate to  the  needs  of  the  occasion.  As  before  stated,  time  will  be  saved 
by  first  clearing  the  streets  in  order  that  teams  and  motors  may  be 
utilized  in  cleaning  up  private  property.  Ditches  must  be  cleared 
or  dug  to  drain  collections  of  water.  If  this  cannot  be  done  with 
sufficient  rapidity  to  prevent  the  incursions  of  mosquitoes,  the  ponds 
must  be  oiled.  Piles  of  drift  must  be  cleared  and  any  dead  animals 
found,  buried  or  burned.  By  the  use  of  a  sufficient  quantity  of 
crude  oil,  very  wet  driftwood  with  its  contents  may  sometimes  be 
burned  in  place  with  a  great  saving  of  effort  and  time.  Cellars  must 
be  i)umpe(l  out,  houses  dried  out  by  artificial  heat,  walls  scraped, 
floors  scrul)b(Ml,  and  places  made  generally  habitable.  If  any  disin- 
fectants are  used,  either  lime  or  the  cresol  derivatives  are  prefer- 
able. 

Earthquakes. — Earth(|uakes  are  frequently  combined  with  fire 
and  flood,  and  in  addition  pivsent  such  i)roblems  as  broken  water 
and  gas  mains  which  the  other  two  do  not  oixlinarily  have.     Brick 


PUBLIC   EMERGENCIES  363 

and  stone  housi'S  wliieh  suffer  least  from  fire  and  flood  suffer  most 
from  earthquake,  and  flimsy  frame  buildings  which  would  be  demol- 
ished by  the  former  are  not  injured  by  the  latter.  Otherwise  the 
work  to  be  done  is  (luite  similar. 

Refugee  Camps. — After  any  considerable  calamity  it  is  generally 
necessary  for  at  least  a  short  time  to  form  refugee  camps.  They 
may  be  operated  by  the  American  National  Red  Cross,  which  works 
in  conjunction  with  the  War  Department,  the  Army,  the  Public 
Health  Service,  the  National  Guard  or  by  local  or  private  assistance. 
In  case  any  of  the  organized  relief  agencies  take  charge  it  will  be 
the  part  of  wisdom  for  the  local  authorities  to  subordinate  them- 
selves for  the  reason  that  these  agencies  are  trained  to  meet  such 
emergencies  and  are  organized  for  this  purpose.  But  it  often  re- 
quires several  days  to  mobilize  these  forces  and  get  them  to  the  spot 
and  in  the  meantime  much  valuable  work  can  be  done.  Shelter 
must  be  improvised  as  rapidly  as  possible,  such  stores  as  are  avail- 
able must  be  collected  and  apportioned,  and  the  people  in  need  of 
them  counted  and  their  necessities  verified.  Daily  inspections 
should  be  made  to  determine  the  presence  or  absence  of  infection,  and 
cook-shacks  and  sleeping  quarters  must  be  carefully  watched.  If 
these  thing:s  are  carefully  looked  after  at  once  it  means  that  much 
valuable  time  is  saved  and  when  the  organized  relief  is  available,  -it 
will  be  much  more  effective. 

Latrines. — The  disposal  of  human  excreta  is  the  hardest  problem 
which  the  sanitarian  has  to  deal  with,  and  yet  the  simplest  measures 
are  the  most  effective.  Privies  of  the  type  described  in  Chapter 
XXXII  with  bucket  or  can  containers  are  all  right  if  properly 
looked  after.  The  modern  military  latrine,  consisting  of  a  fly-tight 
box  with  the  holes  covered  with  close-fitting  lids,  the  box  resting  on  a 
frame  on  the  ground  in  such  a  way  that  it  can  be  lifted  off  to  ex- 
pose the  pit,  is  also  very  gocd.  AVith  this  latrine  the  pit  is  burned 
out  daily  with  an  armful  of  straw  and  a  quart  of  coal  oil  and  the 
box  replaced.  The  excreta  are  not  destroyed  but  are  sterilized  by 
the  heat  and  flies  will  not  enter  if  the  lids  are  kept  closed. 

Incinerators. — The  disposal  of  garbage  is  a  diffieult  but  neces- 
sary task,  and  where  wood  can  be  had  and  stones  or  brick-bats  are 
available  the  matter  is  much  simplified  by  making  an  incinerator  of 
the  type  shown  in  Fig.  -46.  This  is  made  by  digging  a  hole  21^  by 
5  feet,  12  inches  in  depth  at  one  end  and  18  at  the  other.  The 
excavated  earth  is  banked  around  the  outside  and  the  whole  pit  lined 


364 


PRACTICAL    SANITATION. 


with  stones  capable  of  standing  heat,  or  broken  bricks.  A  ridge  is 
then  built  in  the  center  to  cause  a  draft.  The  fire  is  built  of  any 
sort  of  wood  at  hand  and  after  the  stones  are  well  heated,  liquid  gar- 
bage may  be  slowly  poured  around  the  edges  and  the  solid  garbage 
thrown  directly  on  the  fire.     The  average  cook  will  insist  in  putting 


Fig.  46. — Outdoor  incinerator    (Arnold  type). 

the  solid  matter  around  the  edge  where  it  cannot  burn  and  putting 
the  liquid  on  the  fire  to  put  it  out.  Such  an  incinerator  will  care  for 
the  waste  from  more  than  100  people  without  difficulty,  provided  the 
fire  is  kept  going  and  the  ashes  and  tin  cans  are  cleared  out  occasion- 
ally. 

Immunization. — As  soon  as  possible  after  the  establishment  of  a 
refugee  camp,  every  person  should  be  vaccinated  against  smallpox 
and  immunized  against  typhoid.  In  some  localities  and  seasons  it 
may  be  well  to  add  an  immunization  against  other  diseases  as  dysen- 
tery or  Asiatic  cholera.  Measures  designed  to  keep  down  vermin, 
such  as  the  free  application  of  coal  oil,  which  is  likely  to  be  the  only 
insecticide  available,  are  very  necessary  also.  This  part  of  the  work, 
with  the  exception  of  the  eradication  of  vermin,  Mali  probably  have 
to  await  the  coming  of  organized  relief. 


PART  III. 
LABORATORY  METHODS 


CHAPTER  XLI. 
PATHOLOGICAL  MATERIALS. 

General  Considerations. — The  use  of  laboratories  in  the  promo- 
tion of  public  health  work  is  of  very  recent  origin.  The  first  labora- 
tory of  hyigene  was  that  established  for  Pettenkofer  in  Munich  in 
1872.  Here  was  begun  the  study  of  the  relation  of  water  supplies 
to  the  spread  of  typhoid  fever  and  cholera.  By  the  application  of 
facts  learned  in  this  laboratory  concerning  the  disposal  of  sewage, 
the  contamination  of  public  water  supplies,  etc.,  to  sanitary  con- 
ditions in  Munich,  the  city  was  changed  in  a  few  years  from  a  hot- 
bed of  typhoid  fever  to  a  city  in  which  von  Ziemssen  declared  it  was 
impossible  to  find  a  sufficient  number  of  cases  of  this  disease  for  the 
satisfactory  teaching  of  medical  students. 

Puhlic  health  laboratories  differ  both  in  organization  and  in  pur- 
pose from  those  devoted  to  research  or  to  teaching.  In  the  latter, 
the  aim  is  either  the  discovery  of  new  scientific  truth,  or  the  illustra- 
tion of  the  principles  of  a  science  in  such  a  way  that  they  may  be 
more  readily  comprehended  by  students;  in  the  former,  the  aim  is 
the  invention  of  methods  by  which  facts  already  known  can  be  used 
in  the  prevention  of  disease. 

Value  of  Laboratories. — Laboratories  may  be  of  service  in  con- 
serving the  public  health  in  at  least  three  ways.  First,  by  promptly 
discovering  the  earliest  cases  of  certain  infectious  diseases,  such  as 
diphtheria  and  cholera,  epidemics  can  be  more  easily  prevented  by 
taking  proper  measures  before  the  disease  has  become  widespread  in 
the  community.  Second,  by  discovering  the  healthy  carriers  of 
infection,  such  as  persons  who,  though  they  show  no  symptoms, 
discharge  virulent  typhoid  bacilli  or  cholera  spirilla  from  their 
bodies,  or  harbor  diphtheria  bacilli  in  their  noses  and  throats. 
Third,  the  laboratory  can  often  supply  positive  proof  of  the  source 

365 


366  PRACTICAL.  SANITATION. 

of  an  epidemic  of  typhoid  fever  or  other  infectious  disease,  thus 
furnishing  a  rational  and  imperative  demand  for  its  removal. 

It  is  taken  for  granted  that  the  phj^sician  or  health  officer  who 
reads  this  has  an  opportunity  to  make  use  of  a  public  health  labora- 
tory. Hence  it  is  not  the  object  of  this  chapter  to  serve  as  a  hand- 
book of  laboratory  technic.  It  is  intended  to  fulfill  three  distinct 
purposes. 

First,  to  set  forth  general  principles  for  the  proper  methods  of 
collecting,  preparing  and  sending  specimens  to  the  laboratory  in 
order  that  they  may  be  best  utilized. 

Second,  to  give  a  very  general  idea  of  how  specimens  are  handled 
after  they  reach  the  laboratory. 

Third,  to  show  the  practical  application  of  the  results  of  labora- 
tory work  to  the  problems  which  daily  confront  the  local  health 
officer. 

Collection  of  Specimens. — The  manner  in  which  a  specimen  is 
collected  and  prepared  for  transmission  to  the  laboratory  deter- 
mines very  largely  the  accuracy  of  the  results  of  its  examination. 
Practically  all  public  health  laboratories  furnish  free  of  charge 
special  outfits  with  printed  directions  for  collecting  and  sending 
the  various  kinds  of  specimens  to  the  laboratory.  The  outfits  sup- 
plied by  State  laboratories  are  usually  mailable,  those  furnished 
by  city  laboratories  in  most  instances  are  not  mailable.  Local 
health  officers  should  acquaint  themselves  with  the  methods  of  col- 
lecting and  preparing  specimens  required  by  their  own  state  or 
city  laboratories,  not  only  that  they  may  themselves  send  specimens 
correctly,  but  may  be  able  when  necessary  to  instruct  the  physicians 
in  their  jurisdiction  in  such  matters. 

Postal  Laws. — The  United  States  Postal  Laws  and  Regulations 
concerning  the  transmission  of  pathological  and  bacteriological  ma- 
terial through  the  mails  are  very  strict  and  should  be  known  to 
every  health  officer.     These  laws  and  regulations  are  as  follows : 

Section  495,  P.  L.  and  E,.,  as  amended  by  the  Postmaster   General's 
Order   No.   3064,  April  22,   1910. 

Section  495,  Postal  Laws  and  Regulations,  is  liereby  amended  to  read  as 
follows: 

Specimens  of  diseased  tissues  may  be  admitted  to  the  mail  for  transmission 
to  the  United  States,  State,  municipal  or  other  laboratories  in  possession  of 
permits  referred  to  in  paragraph  3  of  tliis  section  only  when  inclosed  in  mail- 
ing  cases   constructed    in   accordance   with    this   regulation:     Provided,    That 


PATHOLOGICAL    MATERIALS.  367 

bacteriologic   or   pathologic   speciuioiis   of   plague   and   cholera   shall   under   no 
circumstances  be  admitted  to  the  mails. 

2.  Liquid  cultures,  or  cultures  of  micro-organisn;s  in  media  tliat  are  fluid 
at  the  ordinary  temperature  (below  45  C.  or  113  F.),  are  unmailable.  Such 
s^pecimens  may  be  sent  in  media  that  remain  solid  at  ordinary  temperature. 

3.  No  package  containing  diseased  tissue  shall  be  delivered  to  any  repre- 
sentative of  any  of  said  laboratories  until  a  permit  shall  have  first  been 
issued  by  tlie  Postmaster  General  certifying  that  said  institution  has  been 
found  to  be  entitled,  in  accordance  with  the  requirements  of  this  regulation, 
to  receive  such  specimens. 

4.  (a)  Specimens  of  tubercular  sputum  (whether  disinfected  with  car- 
bolic acid  or  not  disinfected)  shall  be  transmitted  in  a  solid  glass  vial  with 
a  mouth  not  less  than  one  inch  in  diameter  and  capacity  of  not  more  than 
2  ounces,  closed  by  a  cork  stopper  or  by  a  metallic  screw  top  protected  by  a 
rubber  or  felt  washer.  Specimens  of  diphtheria,  typhoid  or  other  infectious 
or  communicable  diseases  or  diseased  tissues  shall  be  placed  in  a  test  tube 
made  of  tough  glass,  not  over  one-half  inch  in  diameter,  and  not  over 
three  and  one-half  inches  in  length,  closed  with  a  stopper  of  rubber  or  cotton 
and  sealed  with  parafRne  or  covered  with  a  tightly-fitting  rubber  cap. 

(b)  The  glass  vial  or  test  tube  shall  then  be  placed  in  a  cylindrical  tin  box 
made  of  I.  C.  bright  tin  plate,  with  soldered  joints,  closed  by  a  metal  screw 
cover  with  a  rubber  or  felt  washer.  The  vial  or  test  tube  in  this  tin  box 
shall  be  completely  and  evenly  surrounded  by  absorbent  cotton  closely  packed. 

(c)  The  tin  box  with  its  contents  must  then  be  enclosed  in  a  closely-fitting 
metal,  wooden  or  papier-mache  block  or  tube  at  least  3-16  of  an  inch  thick 
in  its  thinnest  part,  of  sufficient  strength  to  resist  rough  handling  and  sup- 
port the  weight  of  the  mails  piled  in  bags.  This  last  tube  to  be  tightly 
closed  with  a  metal  screw  cap. 

5.  Specimens  of  blood  dried  on  glass  microscopic  slides  for  the  diagnosis 
of  malaria  or  typhoid  fever  by  the  Widal  test  may  be  sent  in  any  strong 
mailing  case  which  is  not  liable  to  breakage  or  loss  of  the  specimen  in 
transit. 

6.  Upon  the  outside  of  every  package  of  disease  tissues  admitted  to  the 
mails  shall  be  written  or  printed  the  words,  "Specimen  for  Bacteriological 
Examination.  This  package  to  be  pouched  with  letter  mail.  See  section  495, 
P.  L.  and  R." 

DIPHTHERIA. 

It  is  undoubtedly  true  that  there  has  been  a  greater  reduction  in 
the  mortality  from  diphtheria  during  the  last  fifteen  years  than  in 
its  morbidity.  This  is  due  to  the  fact  that  this  disease  is  now  uni- 
versally treated  scientifically  with  antitoxin,  while  quarantine  is  still 
administered  in  most  communities  in  a  haphazard  irrational  way. 
Release  from  quarantine  should  be  governed  by  the  results  of  bac- 
teriological examination  of  subsequent  cultures  from  the  throat  of 
the  patient.     An  arbitrary  time  limit  of  quarantine  is  not  justifiable 


368  PRACTICAL   SANITATION. 

except  in  localities  where  it  is  entirely  impossible  to  secure  labora- 
tory examinations. 

The  outfits  supplied  by  the  laboratory  of  the  state  or  city  in 
which  the  physician  or  health  officer  resides  should  alone  be  used 
in  taking  all  cultures  to  be  examined  for  diphtheria  bacilli.  Out- 
fits furnished  by  municipal  laboratories  are  usually  non-mailable 
and  contain  a  swab  and  media  to  be  inoculated  by  the  physician. 
Those  furnished  by  most  state  laboratories  consist  of  a  double  mail- 
ing case  with  one  or  two  swabs  but  no  media.  The  tube  of  media 
is  left  out  because  it  frequently  becomes  old,  dry  or  contaminated 
before  use,  resulting  in  loss  to  the  laboratory  or  difficulty  in 
securing  reliable  results,  especially  if  the  swab  is  destroyed  by  the 
doctor.  Better  results  are  also  obtained  if  the  medium  is  inoculated 
by  expert  hands. 

Wooden  skewers,  aluminum,  iron,  brass  or  copper  wire  are  used 
for  making  the  swabs.  Copper  and  brass  give  least  reliable  results 
because  products  of  oxidation  of  the  copper  may  have  an  antiseptic 
effect  upon  the  bacteria  present. 

Very  much  depends  upon  the  manner  in  which  the  swab  is  taken. 
The  health  officer  should  not  only  know  how  cultures  are  to  be 
taken  but  should  be  able  to  instruct  the  physicians  who  report  to  him. 
Every  laboratory  furnishes  directions  which  apply  to  the  particu- 
lar kind  of  outfit  used,  and  with  these  the  health  officer  should  be 
thoroughly  acquainted.  The  following  directions  are  sufficiently 
general  to  apply  to  any  type  of  outfit : 

Throat  Culture. — No  local  antiseptic  application  should  be  made 
for  at  least  2  hours  previous  to  taking  the  culture.  Patient's  throat 
should  be  cleared  of  any  adherent  food  particles,  etc. 

1.  Have  the  patient  in  good  light. 

2.  Rub  the  swab  thoroughly  against  any  membrane,  exudate 
or  inflamed  area  in  the  throat,  revolving  the  swab  in  the  fingers  in 
such  a  way  as  to  bring  it  thoroughly  in  contact  with  the  suspected 
area. 

3.  Do  not  lay  the  swab  down  or  allow  it  to  touch  anything 
other  than  the  throat  of  the  patient  and  the  tube  in  which  it  is 
contained. 

4.  Return  the  swab  to  the  tube,  replace  the  cotton  plug  and 
return  the  tube  to  the  case.  Or,  if  the  outfit  contains  a  tube  of 
culture  medium — 

5.  Insert  the  infected  swab  into  the  serum-tube  and  rub  it  gently 


PATHOLOGICAL    MATERIALS.  369 

back  and  forth  over  the  entire  surface  of  the  serum,  revolving  the 
swab  so  as  to  bring  it  thoroughly  in  contact  with  the  serum.  Do 
not  break  the  surface  of  the  serum  by  pushing  the  swab  through  it. 
Do  not  use  the  medium  if  it  is  dry  or  contaminated.  Replace  the 
infected  swab  in  its  own  tube  and  replace  the  cotton  plugs  in  both 
tubes. 

Nasal  Culture. — Cultures  for  release  must  be  taken  from  both 
the  nose  and  throat  in  all  eases.  Use  one  of  the  two  swabs  in  the 
outfit  for  the  nose  and  the  other  for  the  throat.  Cultures  for  diag- 
nosis may  be  made  from  either  the  nose  or  throat,  or  both,  at  the 
option  of  the  physician. 

1.  The  physician  should  stand  behind  the  patient  who  should 
preferably  be  in  a  sitting  posture,  if  his  condition  allows  it,  place 
the  left  hand  on  the  patient's  chin  and  hold  the  head  firmly  against 
the  body  of  the  operator.  With  the  right  hand  insert  the  swab 
about  one-half  inch  upward  into  the  right  nostril.  Then  raise  the 
hand  so  that  the  shaft  of  the  swab  is  parallel  to  the  floor  of  the 
nose  and  with  gentle  rotation  pass  the  swab  back  to  the  posterior 
pharyngeal  wall.  Withdraw  the  swab  and  repeat  the  process  in 
the  other  nostril. 

2.  Remove  the  swab  and  return  it  to  the  test  tube,  taking  care 
that  it  does  not  touch  any  object  other  than  the  tube  in  which  it 
is  contained.     Replace  the  cotton  plug  and  return  it  to  the  case. 

3.  If  the  outfit  contains  culture  medium  inoculate  it  as  described 
under  ''Throat  Culture"  above. 

The  swab  should  always  be  returned  to  the  laboratory  whether  the 
outfit  contains  medium  or  not.  It  may  be  necessary  to  reinoculate 
the  medium  if  the  culture  fails  to  grow. 

All  state  laboratories  are  handicapped  by  the  fact  that  it  is 
usually  8  to  24  hours  after  the  swab  has  been  taken  from  the 
throat  before  it  is  delivered  at  the  laboratory.  This  necessitates 
some  delay  in  getting  the  report  to  the  physician.  The  difficulty 
can  be  partially  obviated  by  the  method  in  use  in  many  labora- 
tories. As  soon  as  the  specimen  is  received,  a  culture  is  made 
and  a  smear  from  the  swab  examined.  In  this  way,  from  50  to  80 
per  cent  of  all  positive  specimens  can  be  reported  within  an  hour 
after  they  reach  the  laboratory.  Where  there  is  the  slightest 
doubt  as  to  the  findings  on  the  swab,  the  case  is  not  reported  until 
the  culture  has  been  examined.  Smears  are  made  from  the  cul- 
tures at  the  end  of  6  or  8  hours  and  from  5  to  20  per  cent  more 


370  rRACTICAL   SANITATION. 

are  reported.     No  case  can  be  safely  pronounced  negative  from 
the  swab  alone. 

A  culture  may  be  positive,  negative,  suspicious,  contaminated, 
or  may  fail  to  grow  entirely.  A  positive  report  cancels  all  pre- 
vious negatives  on  the  same  case.  A  negative  report  may  be  due 
to  (a)  Absence  of  B.  Diphtherice  from  the  throat;  (b)  Failure  to 
reach  bacilli  with  the  swab  as  may  happen  in  laryngeal  diphtheria 
and  in  pharyngeal  cases  from  improper  technic;  (c)  Failure  to 
inoculate  the  medium  properly,  which  is  not  likely  to  occur  if  the 
inoculation  is  done  by  an  expert  in  the  laboratory;  (d)  A  very 
few  diphtheria  bacilli  in  the  presence  of  many  varieties  may  be 
overlooked  by  the  bacteriologist.     This  is  an  infrequent  occurrence. 

"When  a  "suspicious  organism"  is  reported  present  a  second 
culture  should  be  sent  at  once.  The  patient  should  be  temporarily 
isolated  and  antitoxin  administered  if  the  symptoms  indicate  it.  In 
most  laboratories  suspicious  cultures  are  reinoculated  and  rein- 
cubated  when  a  second  examination  will  usually  give  more  definite 
results. 

AVhen  the  culture  fails  to  grow  no  diagnosis  can  be  made  and  a 
second  culture  must  be  sent  at  once.  "No  growth"  may  be  due 
(a)  to  use  of  an  antiseptic  in  the  throat  previous  to  taking  the 
culture;  or  (b)  to  failure  to  properly  inoculate  the  medium. 

' '  Contamination ' '  may  occur  from  various  sources.  No  diagnosis 
can  be  made  and  a  second  culture  is  required.^ 

The  tendency  on  the  part  of  many  physicians  to  either  magnify 
or  minimize  the  results  of  bacteriologic  examination  is  a  frequent 
cause  of  unnecessary  and  irrational  complaints  which  every  health 
officer  should  be  able  to  answer.  That  it  is  not  safe  for  a  physician 
to  depend  solely  upon  the  appearance  of  the  throat  for  diagnosis 
is  shown  by  the  records  of  various  laboratories.  At  the  Boston 
City  Laboratory  it  was  found  that  "when  a  physician  makes  defi- 
nitely a  positive  clinical  diagnosis  at  the  time  of  taking  the  culture, 
bacilli  are  found  in  68  per  cent  of  the  cases,  and  that  when  he  makes 
a  definitely  negative  diagnosis  .  .  .  bacilli  are  found  in  11  per  cent 
of  the  cases."  In  the  Philadelphia  City  Laboratory,  diphtheria 
bacilli  were  found  in  83  per  cent  of  cases  diagnosed  diphtheria  clinic- 
ally, in  35  per  cent  of  those  diagnosed  "not  diphtheria,"  and  in  46 
per  cent  in  which  the  diagnosis  was  doubtful.     At  the  Chicago  labo- 

'  Modified  from  Report  of  Committee  on  Throat  Cultures,  Section  on  Preventive  Medi- 
cine of  the  American  Medical  Association,  Journal  American  Medical  Association,  1911, 
LVII,   976. 


PATHOLOGICAL   MATERIALS. 


371 


ratory  cultures  from  only  34  per  cent  of  cases  diagnosed  diphtheria 
contained  diphtheria  bacilli,  13  per  cent  of  those  pronounced  tonsil- 
litis, and  8.6  per  cent  of  those  in  which  the  physician  did  not 
venture  a  diagnosis.     These  results  may  be  tabulated  as  follows; 


Indiana 

Boston 

Philadel])liia 

83%. 

Cliieago 

34% 

13%; 

8.6% 

Average 

Clin.    diag.   positive.  . 
liact.  diag.  positive.. 

53.8% 

08% 

59.7% 

Clin.  diag.  negative.. 
Baet.  diag.  positive.. 

26.2% 

11% 

35% 
40% 

21.3% 

Clin.  diag.  doubtfuL. 
Bact.  diag.  positive.. 

28.1% 

27% 

27.7% 

Comparisons  of  clinical  and  bacteriological  diagnosis  may,  how- 
ever, be  somewhat  misleading.  The  physician  may  change  his  diag- 
nosis even  before  he  receives  the  report  of  the  examination  at  the 
laboratory.  Unfortunately,  the  failure  to  find  B.  DiphtJierim  in  a 
culture  does  not  always  indicate  correctly  the  absence  of  the  dis- 
ease of  diphtheria.  A  very  small  percentage  of  cases  of  true  diph- 
theria are  negative  on  first  culture  and  positive  on  the  second  or 
third.  For  this  reason  more  than  one  culture  should  always  be 
sent  from  every  ease  of  suspicious  sore  throat  if  the  first  culture 
fails  to  show  Klebs-Loffler  bacilli.  The  finding  of  B.  Diphtherice 
in  a  culture  does  not  necessarily  mean  that  the  patient  has  the 
disease  of  diphtheria.  It  does  prove,  however,  that  he  is  carrying 
the  bacilli  of  diphtheria  and  is  therefore  a  source  of  danger  to 
the  public. 

"Carriers." — The  problem  of  dealing  with  healthy  diphtheria 
bacillus  carriers  is  always  a  troublesome  one.  It  is  difficult  to  con- 
vince many  persons  that  a  patient  who  has  entirely  recovered  from 
diphtheria  or  a  healthy  contact  with  no  symptom  whatever  of  the 
disease  may  be  a  source  of  danger  to  the  public  for  days,  weeks  or 
even  months.  In  considering  this  question  three  facts  must  be 
borne  in  mind:  (1)  that  because  of  an  immunity,  natural  or  ac- 
quired, certain  persons  can  harbor  virulent  diphtheria  bacilli  in 
their  throats  without  suffering  any  impairment  of  health;  (2)  that 
diphtheria  antitoxin  neutralizes  the  toxin  in  the  blood  but  has  no 
effect  whatever  on  causing  the  bacilli  to  disappear  from  the  throat ; 
(3)  that  the  bacilli  in  the  throats  of  healthy  carriers  may  be  highly 
virulent. 


372  PRACTICAL   SANITATION. 

"Wesbrook  and  his  coworkers  examined  478  children  in  a  school 
in  which  there  was  an  epidemic  of  diphtheria.  They  found  diph- 
theria bacilli  present  in  the  throats  of  172  children,  104  of  whom 
(60.5  per  cent)  showed  no  symptoms  of  the  disease.  The  writer 
found  that  of  264  first  cultures  from  patients  with  no  symptoms 
of  diphtheria,  42  contained  diphtheria  bacilli.  On  the  other  hand, 
Park  and  Beebe  examined  the  throats  of  320  healthy  persons  who 
had  had  no  direct  contact  with  diphtheria  patients  and  found 
diphtheria  bacilli  in  8  (2  per  cent).  Only  two  of  these  later  devel- 
oped the  disease.  In  regard  to  healthy  carriers,  the  conclusions  of 
the  "Committee  of  the  Massachusetts  Association  of  Boards  of 
Health ' '  are  sufficiently  correct  for  practical  purposes,  namely  that 
*'in  urban  communities,  at  least  1  to  2  per  cent  of  well  persons 
among  the  general  public  are  infected  with  diphtheria  bacilli  and 
that  where  persons  are  exposed  to  diphtheria,  as  in  families,  schools, 
or  institutions  where  cases  exist,  the  number  infected  is  much  larger 
and  may  range  from  8  to  50  per  cent. ' ' 

Persistence  of  Infection. — Woodhead  found  that  the  average 
period  of  persistence  of  diphtheria  bacilli  in  the  throats  of  con- 
valescents was  51  days  and  observed  no  appreciable  difference  be- 
tween patients  treated  with  and  without  antitoxin.  This  is  the 
longest  average  period  of  persistence  of  any  author,  the  general 
average  is  in  the  neighborhood  of  25  days.  Tjaden  studied  1,358 
positive  cases  in  Bremen  and  found  67  per  cent  were  free  from 
bacilli  after  2  weeks,  75  per  cent  after  3  weeks,  84  per  cent  after  4 
weeks,  93.4  per  cent  after  6  weeks.  He  found  that  diphtheria 
bacilli  disappeared  more  rapidly  from  the  throats  of  persons  over 
14  years  of  age  than  from  those  of  younger  children.  Thus,  6  weeks 
after  an  attack  of  diphtheria,  Klebs-Loffler  bacilli  were  found  in 
3.5  to  3.8  per  cent  of  patients  under  14  and  in  only  0.7  per  cent  of 
those  above  that  age. 

That  these  persisting  bacilli  are  fully  virulent  has  been  proved 
by  innumerable  observations.  The  longest  periods  of  persistence 
of  virulent  diphtheria  bacilli  are  those  reported  by  Prip,  235  days ; 
Schaefer,  230  days;  Belfanti,  215  days.  The  bacilli  from  the 
throats  of  healthy  contacts  are  equally  virulent  as  shown  by  the 
following  table :  ^ 


'  Slightly  modified  from  the  Bacteriology  of  Diphtheria,   edited  by  Nuttall  and  Graham- 
Smith,    Cambridge,    1908,   p.   232. 


PATHOLOGICAL    MATERIALS. 


373 


Table  Showing  the  Virulence  of  Diphtheria  Bacilli  Isolated  from 
Healthy  Contacts. 


Observer. 

No.  tested 
for  virulence. 

Fully  virulent. 

Totally  nonvirulent 
or  causing  a  slight 
infiltration. 

Parke   and   Becbe 

Aaser    

Bolton    

Mueller     

Ivober     

12 
17 
88 
12 
15 
9 
56 

11 

17 
88 

6 
15 

6 
38 

1 
0 
0 
6 
0 

Kobbett    

Graham-Smith    .. 

3 

18 

Totil    

227 

181(80%) 

28(20%) 

"These  records  clearly  show  that  the  majority  of  well  persons 
harboring  diphtheria  bacilli  which  have  been  derived  by  contact 
from  clinical  cases,  retain  in  their  throats  fully  virulent  organisms, 
and  that  the  transference  of  virulent  diphtheria  bacilli  from  a 
diseased  to  an  immune  person  does  not  tend  to  weaken  its  viru- 
lence." ^ 

Summary. — 1.  The  fact  that  a  large  number  of  cases  diagnosed 
"not  diphtheria"  clinically  prove  positive  on  bacteriological  exam- 
ination and  vice  versa,  demonstrates  the  importance  of  taking  cul- 
tures from  every  sore  throat,  regardless  of  the  age  of  the  patient, 
or  the  severity  of  the  symptoms. 

2.  '  It  is  likewise  important  in  combatting  the  spread  of  this  dis- 
ease to  take  cultures  from  the  throats  of  every  person  who  has  come 
in  contact  with  a  case  of  diphtheria. 

3.  All  persons  whose  throat  cultures  contain  diphtheria  bacilli, 
whether  suffering  from  any  symptoms  of  the  disease  or  not,  are 
sources  of  danger  to  the  public.  They  should  be  placed  in  quar- 
antine and  kept  there  until  at  least  one  culture  shows  that  these 
bacilli  have  disappeared.  Numerous  experiments  show  that  the 
bacilli  in  the  throats  of  healthy  contacts  are  almost  invariably 
virulent. 

4.  The  administration  of  antitoxin  has  little  or  nothing  to  do 
with  the  disappearance  of  diphtheria  bacilli  from  the  throat. 

5.  An  arbitrary  time  of  quarantine  is  not  justifiable.  Eelease 
from  quarantine  should  be  governed  entirely  by  the  results   of 

iJbid.,  p.  233. 


374  PRACTICAL   SANITATION. 

bacteriological  examination  of  subsequent  cultures  from  tlie  throat 
of  the  patient. 

TUBERCULOSIS. 

Diagnosis. — The  diagnosis  of  tuberculosis  in  public  health  labora- 
tories involves  the  examination  of  sputum,  urine  and  pus  and 
other  discharges,  and  tissues.  While  tuberculosis  is  spread  chiefly 
by  means  of  sputum,  urine,  pus  and  other  discharges  may  become 
a  danger  to  the  public  health  through  the  agency  of  flies.  In  state 
and  municipal  laboratories  the  examination  of  tissues  for  evidence 
of  tuberculosis  is  usually  limited  chiefly  to  sections  of  animal  tissues 
sent  by  inspectors  of  slaughter  houses. 

Sputum  Outfits. — The  outfits  supplied  by  most  public  labora- 
tories for  the  collection  of  sputum  consists  of  a  heavy  wide-mouthed 
bottle,  with  a  cork  stopper,  and  packed  for  mailing  according  to 
the  United  States  Postal  Laws  and  Eegulations.  (See  page  366.) 
In  the  bottle  is  usually  a  5  per  cent  solution  of  carbolic  acid. 
It  has  been  found  by  careful  estimation  that  a  patient  Avith  fairly 
well  advanced  case  of  tuberculosis  discharges  every  24  hours  in 
his  sputum  from  500,000,000  to  3,000,000,000  tubercle  bacilli. 
The  handling  of  disinfected  sputum  may  thus  be  a  very  real  source 
of  danger  to  the  bacteriologist,  especially  if,  as  frequently  happens, 
an  improper  mailing  case  is  used  and  the  bottle  becomes  smashed 
in  the  mails. 

Directions  for  Collecting  Sputum. — Do  not  pour  out  the  solu- 
tion of  carbolic  acid  contained  in  the  bottle.  Collect  the  sputum 
in  the  morning  before  the  patient  has  taken  any  food,  or  after  a 
severe  paroxysm  of  coughing.  If  expectoration  is  scanty,  save  the 
entire  amount  coughed  up  in  24  hours.  Carefully  avoid  contents  of 
the  stomach,  particles  of  food,  etc.  Give  only  what  is  coughed  up 
from  the  lungs.  See  that  the  cork  is  inserted  tightly,  wash  the 
outside  of  the  bottle  thoroughly  in  hot  soap  suds,  and  dry  before 
repacking. 

Directions  for  Collecting  Urine. — Containers  are  not  usually 
supplied  by  laboratories  for  the  collection  of  specimens  of  urine. 
The  urine  should  always  be  obtained  by  a  physician  or  competent 
nurse.  Great  care  should  be  taken  to  clean  the  meatus  thoroughly, 
and  the  urine  should  be  drawn  with  a  sterile  catheter  into  a  sterile 
bottle  (preferably  with  rubber  or  glass  stopper),  with  the  utmost 
precautions  to  avoid  contamination,  and  sent  at  once  to  the  labora- 


PATHOLOGICAL    MATERIALS.  375 

tory.  In  the  case  of  male  patients  it  is  sometimes  sufficient  to 
collect  the  last  half  of  the  urine  passed  in  the  normal  way  after 
careful  cleansing  of  the  meatus.  If  at  some  distance  from  the 
laboratory  the  specimen  should  be  packed  in  ice  for  transmission. 
In  place  of  ice,  formalin  may  be  added  in  the  proportion  of  1  per 
cent  by  volume. 

Directions  for  Collecting  Pus. — Pus  from  a  freshly  opened  ab- 
scess is  to  be  preferred.  If  an  old  sinus  exists  it  should  be  scraped 
with  a  dull  curette,  and  the  scrapings  sent  with  as  much  pus  as 
possible.  Sputum  outfits  are  convenient  for  the  transportation  of 
pus.  But  the  carbolic  solution  should  be  poured  out  and  the  bottle 
and  cork  boiled  before  using.^ 

Directions  for  Collecting  Pathological  Tissues. — Diseased  or- 
gans or  parts  of  them  may  be  wrapped  in  gauze  and  packed  in  ice,  or 
placed  unwrapped  in  a  5  per  cent  solution  of  formalin  (1  part  com- 
mercial formalin  and  19  parts  water) . 

Smears  may  be  made  directly  from  the  sputum,  pus,  or  sediment 
obtained  from  the  urine  by  centrif ugalization ;  or  the  material 
may  be  shaken  up  with  an  alkaline  solution  of  sodium  hypochlorite. 
By  the  latter  method,  sometimes  called  the  "antiformin"  method, 
the  mucus,  pus  cells  and  ordinary  bacteria  are  thoroughly  digested ; 
the  tubercle  bacilli  being  protected  by  a  waxy  capsule  are  left 
unchanged.  The  digested  material  is  then  centrifugalized  and  all 
the  tubercle  bacilli  in  the  whole  specimen  are  concentrated  in  a 
small  mass,  smears  from  which  are  made  and  stained  in  the  usual 
way. 

The  greater  accuracy  of  the  so-called  antiformin  method  over 
the  ordinary  method  is  shown  in  the  following  table  which  is  based 
on  the  examinations  of  one  month : 

Ordixary  Examinations  : 

Total  number  of  spenimens  examined     339 

Total  number  of  specimens  positive    96 

Per  cent  positive   28.3 

Antiformin  Examinations  : 

Total  number  specimens  examined    74 

Total  number  specimens     positive    8 

Per  cent  positive   10.8 

Total  number  of  sputum  specimens  received  during  montli..    339 

^  The  above  directions  are  modified  from  the  Report  of  the  Committee  on  Standard 
Methods  for  the  Bacteriologic  Diagnosis  of  Tuberculosis,  Jour.  Amer.  Pub.  Health  Assoc, 
1911,   I,   273. 


376  PRACTICAL  SANITATION. 

Positive  by  ordinary  examination   28.3% 

Pos.  by  combined  ordinary  and  antiformin  ex 30.65% 

Increase  by  combined  method   ' 2.35% 

All  specimens  were  examined  by  the  ordinary  method  and  only 
those  were  treated  with  the  alkaline  hypochlorite  which  were  diag- 
nosed tuberculosis  clinically  and  found  negative  by  the  usual 
method  of  bacteriological  examination. 

The  Guinea-Pig  Test. — It  is  often  desirable  to  inject  a  guinea- 
pig  wdth  material  supposed  to  be  tuberculous.  Hence  the  neces- 
sity of  great  care  in  collecting  specimens  of  urine,  pus,  etc.,  to 
prevent  contamination.  The  guinea-pig  is  injected  either  intra- 
peritoneally  or  subcutaneously  with  some  of  the  suspected  matter. 
If  the  pig  does  not  die  of  the  disease  it  is  killed  at  the  end  of  6  to  8 
weeks  and  the  body  examined  at  autopsy. 

TYPHOID  FEVER. 

Diagnosis. — Public  health  laboratories  are  concerned  with  the 
diagnosis  of  typhoid  fever  and  the  discovery  of  typhoid  bacilli 
carriers.  The  laboratory  tests  applicable  to  the  diagnosis  of  typhoid 
fever  are  the  Widal  and  diazo  reactions  and  hlood  cultures.  The 
Widal  or  agglutination  test  is  the  one  most  universally  used. 

Toxins. — Bacteria  may  be  roughly  divided  into  two  great  classes, 
namely,  those  which  produce  soluble  toxins  in  the  medium  in  which 
they  grow,  as,  for  example,  the  hacillus  of  diphtheria,  and  those 
which  do  not  produce  soluble  toxins  such  as  the  bacillus  of  typhoid 
fever.  The  human  body  reacts  differently  to  infections  with  organ- 
isms of  these  two  groups.  In  response  to  infections  by  members 
of  the  first  group,  antitoxins  are  produced  which  neutralize  the 
poisons  elaborated  by  the  infecting  bacteria.  Typhoid  bacilli  and 
other  members  of  the  second  group,  on  the  other  hand,  stimulate 
the  formation  of  a  variety  of  antibodies  which  act  upon  the  bacterial 
cell  itself,  such  as  hactenolysins,  agglutinins,  etc.  It  is  upon  the 
presence  of  agglutinins  in  the  blood  of  a  typhoid  patient  that  the 
Widal  test  depends.  The  agglutinins  present  in  the  blood  are 
specific  for  the  organism  causing  the  infection.  Hence  a  similar 
test  can  be  applied  in  the  diagnosis  of  a  number  of  other  diseases, 
such  as  para-typhoid  fever,  cholera,  dysentery,  Malta  fever,  etc. 

Specificity  of  Agglutinins. — Because  of  the  specificity  of  agglu- 
tinins, the  agglutination  test  has  proved  of  very  great  value  in  the 
quick  and  accurate  identification  of  bacteria.     If  a  bacillus  isolated 


PATHOLOGICAL    MATERIALS,  377 

from  a  patient's  stool  agglutinates  with  a  known  typhoid  immune 
serum,  it  is  immediately  recognized  as  B.  typhosus. 

Agglutination  Test. — The  agglutinating  power  of  a  serum  may 
be  tested  by  either  the  microscopic  or  the  macroscopic  method.  For 
the  identification  of  unknown  bacteria  the  latter  method  is  pref- 
erable; for  the  ordinary  diagnostic  test  the  microscopic  method 
is  most  generally  used. 

For  the  purpose  of  the  Widal  reaction  dilutions  of  the  patient's 
serum  in  the  proportions  of  1  to  20,  1  to  30,  and  1  to  50  are  made.' 
One  loopful  of  these  dilutions  mixed  on  a  coverslip  with  a  loopfu^ 
of  a  fresh  broth  culture  make  final  dilutions  of  the  serum  1  to  4C 
1  to  60,  and  1  to  100.  When  these  mixtures  are  observed  in  the 
hanging  drop  under  the  microscope  if  the  serum  contains  agglu- 
tinins, the  bacilli  will  be  seen  to  gradually  lose  their  motility,  to 
gather  together  into  large  clumps  and  to  be  drawn  away  from  the 
edges  of  the  drop.  This  process  must  be  completed  within  2  hours. 
All  degrees  of  completeness  of  reaction  are  seen  in  actual  practice. 
In  a  frankly  positive  reaction  no  free  motile  bacilli  will  be  seen. 
In  a  definitely  negative  reaction  there  is  no  loss  of  motility  and  no 
clumping.  In  other  instances  a  variable  number  of  organisms  will 
be  seen  swimming  in  the  drop,  others  lying  motionless  and  isolated, 
while  the  remainder  are  collected  into  larger  or  smaller  clumps. 

The  following  are  the  possibilities  in  a  microscopical  Widal  test: 

1.  Loss  of  motility  complete,  agglutination  complete. 

2.  Loss  of  motility  complete,  agglutination  incomplete. 

3.  Loss  of  motility  incomplete,  agglutination  incomplete. 

4.  Loss  of  motility  absent,  agglutination  absent. 

The  first  statement  indicates  a  frank  positive  test  and  the  last  an 
equally  definitive  negative  reaction.  The  second  and  third  possi- 
bilities must  be  interpreted  as  negative,  but  are  sufficiently  "sug- 
gestive ' '  to  require  the  sending  of  blood  for  another  test. 

Macroscopic  Metliod. — The  macroscopic  method  requires  24  hours. 
The  proper  amount  of  the  patient's  serum  is  added  to  a  suspension 
of  typhoid  bacilli  in  a  small  test  tube  and  allowed  to  stand  for  24 
hours.  At  the  end  of  this  time,  in  a  positive  reaction,  the  bacilli 
will  have  collected  into  clumps  which  settle  to  the  bottom  of  the 
tube  in  an  irregular  mass  easily  distinguishable  from  the  even 
layer  of  sediment  in  the  control  tube  which  contained  no  serum. 


*  As  a  rule,   only  dilutions  of   1   to  30   are  used   for  routine  examinations. 


378  PRACTICAL  SANITATION. 

The  fluid  in  the  control  tube  will  be  turbid,  in  the  other  perfectly 
clear. 

Outfits. — Each  public  health  laboratory  has  its  own  special 
outfit  which  is  furnished  to  physicians  for  collecting  blood  for  the 
Widal  test.  These  range  from  mica  plate,  aluminum  or  tin  foil,  a 
glass  slide  or  a  bit  of  filter  paper  on  which  a  few  drops  of  dried 
blood  may  be  sent,  to  small  glass  bulbs  in  which  whole  blood  may 
be  obtained. 

Collection  of  Blood. — The  use  of  whole  blood  from  which  the 
serum  can  be  separated  and  accurately  diluted  is  far  more  accurate 
than  the  use  of  dried  blood.  For  bleeding  into  these  bulbs  the 
following  directions  should  be  observed : 

1.  "With  clean  fingers  break  off  neatly  and  squarely  the  tips  of 
both  ends  of  the  spindle-shaped  glass  bulb. 

2.  Cleanse  lobe  of  patient's  ear  or  tip  of  his  finger  with  soap 
and  water,  followed  by  alcohol,  and  prick  it  well  with  a  sterile 
needle.     A  large-sized  straight  Hageclorn  is  the  best. 

3.  As  the  blood  wells  out,  holding  the  tube  horizontal  place 
one  end  in  the  drop  and  allow  the  spindle-shaped  bulb  to  fill  at 
least  one-half  full.  Three  or  four  large  drops  will  be  sufficient.  If 
too  small  a  needle  has  been  used  the  blood  may  not  well  out  so 
freely  and  the  finger  or  lobe  of  the  ear  may  have  to  be  gently 
"milked."    Fill  the  tube  from  one  end  only. 

4.  When  the  bulb  is  half  full  seal  off  the  empty  end  of  the 
tube  in  the  flame  of  a  candle  or  match.  As  soon  as  this  cools,  shake 
the  blood  into  the  sealed  end  with  a  motion  like  that  with  which 
you  shake  down  your  thermometer.  Then  seal  off  the  other  end. 
Be  sure  that  both  ends  are  completely  sealed. 

When  dried  blood  is  used  the  dilutions  must  be  made  by  mixing 
with  physiological  salt  solution  a  weighed  amount  of  the  dry  blood, 
or  the  dilution  guessed  at  by  mixing  the  blood  with  a  sufficient 
salt  solution  to  bring  it  to  a  standard  shade  of  color.  The  latter 
method  may  often  be  grossly  inaccurate,  and  even  weighing  the 
blood  is  sometimes  only  slightly  less  so. 

Percentage  of  Positive  Test. — The  Widal  test  is  positive  in  the 
first  week  of  typhoid  fever  in  small  percentage  of  cases;  it  is  posi- 
tive in  the  second  week  in  about  70  per  cent  of  cases;  in  the  third 
week  in  95  per  cent ;  and  in  a  very  small  per  cent  it  does  not  appear 
until  the  patient  is  convalescent.  Because  of  this  great  irregularity 
in  the  appearance  of  the  reaction  a  single  negative  result  has  no 


PATHOLOGICAL   MATERIALS.  379 

diagnostic  significance  if  taken  alone.  In  the  presence  of  frank 
clinical  symptoms  of  typhoid  fever  a  negative  Widal  test  should 
have  no  weight  whatever.  In  any  obscure  suspicious  case  in  which 
symptoms  continue  for  several  days  after  a  negative  reaction  has 
been  obtained,  another  specimen  should  be  sent  for  examination. 
The  fact  that  the  blood  may  contain  typhoid  agglutinins  for  weeks, 
months  and  occasionally  for  years  after  an  attack  of  typhoid  fever 
should  be  remembered  in  interpreting  a  positive  Widal  test.  As 
in  the  case  of  all  laboratory  tests,  the  "Widal  reaction  must  be 
interpreted  in  connection  with  the  clinical  symptoms  and  physical 
findings  in  the  case,  and  should  never  be  made  the  sole  basis  of  a 
diagnosis.  The  fact  that  agglutinins  are  present  for  several  years 
after  anti-typhoid  inoculation  should  be  borne  in  mind,  and  in 
case  the  patient  has  been  so  treated  the  Widal  test  is  not  to  be 
relied  on  and  a  blood  culture  should  be  made. 

DiAzo  Reaction. — Most  public  health  laboratories  test  urine  for 
Ehrlicli's  diazo  reaction  when  requested  to  do  so.  This  test,  while 
not  possessing  the  value  in  differential  diagnosis  originally  ascribed 
to  it,  is  of  some  clinical  importance.  When  the  reaction  is  positive, 
typhoid  fever  is  to  be  strongly  suspected.  It  is  not  infrequently 
positive,  however,  in  other  pathological  conditions.  "On  the  basis 
of  this  reaction,  Ehrlich  divided  diseases  into  four  classes:  non- 
febrile  diseases  in  which  the  test  is  rarely  positive;  febrile  dis- 
eases in  which  it  is  never  positive,  such  as  acute  articular  rheuma- 
tism and  meningitis;  febrile  diseases  in  which  it  may  be  positive, 
such  as  pneumonia,  diphtheria  and  phthisis;  and  febrile  diseases 
in  which  it  is  almost  constantly  positive,  as  measles  and  typhoid 
fever."  (Emerson.)  The  reaction,  if  present  at  all  in  typhoid 
fever,  usually  appears  between  the  middle  of  the  first  and  the 
middle  of  the  second  weeks. 

When  the  diazo  reaction  is  desired,  3  or  4  ounces  of  urine 
should  be  sent  in  a  clean  bottle. 

Blood  cultures  furnish  the  most  useful  method  for  the  early 
diagnosis  of  typhoid  fever.  When  cultures  are  properly  made 
typhoid  bacilli  will  be  found  in  the  blood  during  the  first  week 
of  the  disease  in  nearly  90  per  cent  of  the  cases.  On  account  of  the 
very  exact  technique  required,  this  test  cannot  be  made  as  a 
matter  of  routine  in  public  health  laboratories. 

Carriers. — The  examination  of  stools  for  typhoid  bacilli  is 
rarely  made  for  diagnostic  purposes  except  in  obscure   or  mild 


380  PRACTICAL   SANITATION. 

ambulant  cases.  They  are  not  usually  found  in  the  stools  until 
well  into  the  second  week,  "about  the  time  that  the  intestinal 
lesions  are  well  advanced  and  ulceration  is  occurring."  Such  ex- 
aminations of  the  stools  of  convalescents  or  of  persons  who  have 
previously  had  typhoid  fever  may  furnish  information  of  very  great 
sanitary  importance.  By  this  means  alone  typhoid  bacilli  carriers 
are  discovered.  Such  persons,  though  perfectly  well  themselves, 
may  discharge  virulent  typhoid  bacilli  for  weeks,  months,  and 
even  years  after  having  the  disease. 

Danger  of  Carriers. — The  importance  of  these  healthy  carriers 
in  the  spread  of  typhoid  infection  has  only  been  recognized  within 
the  last  few  years.  It  has  been  estimated  that  from  2  to  4  per 
cent  of  all  persons  who  have  had  typhoid  fever  continue  to  dis- 
charge the  bacilli  for  more  than  2  months  after  complete  recovery. 
The  danger  of  a  carrier  to  his  associates  and  to  the  general  public 
will  depend  upon  his  occupation  and  his  habits  of  personal  clean- 
liness. Of  51  chronic  bacilli  carriers  reported  in  the  literature, 
33  were  known  to  have  been  the  cause  of  the  disease  in  others.  Of 
these,  13  were  dairy  workers,  10  were  cooks,  7  were  housewives, 
and  3  were  laundresses.  Hence  those  ''carriers"  who  have  any- 
thing to  do  with  the  production  and  handling  of  foods,  especially 
food  which  is  eaten  uncooked,  are  most  dangerous.  It  is  important 
to  note  also  that  about  90  per  cent  of  all  typhoid  bacilli  carriers 
are  women,  Avho,  in  most  families,  prepare  the  food  for  the  table. 

Stools. — The  examination  of  stools  for  typhoid  bacilli  is  diifficult 
on  account  of  the  preponderance  of  other  bacteria,  especially  colon 
bacilli.  For  such  an  examination,  at  least  1  ounce  of  the  stool 
should  be  sent  to  the  laboratory  in  a  wide-mouthed  sterile  bottle. 
The  longer  the  period  of  time  allowed  to  elapse  between  the 
passage  of  the  stool  and  its  receipt  at  the  laboratory,  the  less  likely 
is  the  search  for  typhoid  bacilli  to  be  successful.  B.  typJiosus  has 
been  isolated  from  stools  48  hours  old. 

Differential  Media. — Various  special  media  have  been  pro- 
posed for  the  purpose  of  differentiating  B.  typliosus  from  B.  Coli 
and  the  numerous  other  varieties  of  bacteria  found  in  the  intestine. 
A  medium  first  described  by  Endo  appears  to  be  recognized  as  the 
most  satisfactory.  This  consists  of  a  slightly  alkaline  lactose  agar 
to  which  is  added  a  solution  of  fuchsin  and  sodium  sulphite.  In 
alkaline  solutions  the  fuchsin  is  decolorized  by  the  sulphite,  but  re- 
gains its  deep  red  color  as  soon  as  the  solution  is  rendered  acid. 


PATHOLOGICAL   MATERIALS.  381 

Colon  bacilli  growing  on  Endo's  medium  ferment  the  lactose  with 
the  production  of  acid,  hence  the  colonies  of  B.  Coli  are  deep  red 
in  color.  Typhoid  bacilli,  on  the  other  hand,  do  not  ferment 
lactose  and  grow  as  translucent  colorless  colonies.  In  searching 
for  B.  typhosus  in  stools,  plates  of  Endo's  medium  are  inoculated 
with  dilutions  of  the  fecal  matter  and  incubated  for  24  hours. 
Cultures  are  then  made  from  a  number  of  colorless  colonies  and 
these  are  identified  accurately  by  culture  or  agglutination  tests. 

Vaccine. — A  number  of  state  and  municipal  laboratories,  are 
now  supplying  antityphoid  vaccine  to  physicians  and  health  officers. 
This  method  of  prophylaxis  against  typhoid  fever  has  passed  the 
stage  of  experiment  and  its  use  among  persons  in  civil  life  will 
undoubtedly  greatly  increase. 

The  vaccine  consists  of  a  suspension  in  physiological  salt  solution 
of  killed  typhoid  bacilli.  Each  dose  contains  from  five  hundred 
million  to  one  billion  organisms.  Three  injections  are  given  at 
intervals  of  ten  days.  After  each  injection  there  is  usually  more 
or  less  reaction  which  may  be  local  or  general  or  both.  In  95  per 
cent  of  the  cases  the  reaction  is  no  worse  than  the  onset  of  a  cold 
and  is  followed  by  prompt  recovery.  In  less  than  1  per  cent  of 
the  cases,  the  reaction  is  severe  and  may  be  accompanied  by  fever, 
chills,  herpes,  nausea,  vomiting  and  diarrhea.  These  symptoms 
pass  off  in  48  to  72  hours.  The  immunity  produced  by  injections 
of  antityphoid  vaccine  lasts  at  least  3  years;  it  is  not  known  for 
how  much  longer. 

Two  facts  should  be  clearly  understood  in  connection  with  anti- 
typhoid vaccination.  First,  the  material  injected  is  a  vaccine 
(baCterin)  and  not  a  serum.  Second,  that  the  use  of  this  method 
of  prophylaxis  is  to  supplement  and  not  supplant  general  sanitary 
measures. 

MALARIA. 

Diagnosis. — Practically  all  public  health  laboratories  examine 
smears  for  malarial  parasites.  The  success  of  such  an  examination 
depends  very  largely  upon  the  thinness  and  evenness  with  which 
the  smear  is  made.  The  official  "Malaria  Outfits"  furnished  by 
different  laboratories  consist  essentially  of  two  or  more  cover-glasses 
or  microscopic  slides  in  a  container  suitable  for  mailing.  Smears 
should  be  made  in  the  following  manner : 

Collection  op  Specimen. — After  carefully  cleansing  the  lobe  of 


382  PRACTICAL   SANITATION. 

the  ear  or  the  ball  of  the  finger  prick  it  with  a  large,  sharp  needle. 
Allow  a  drop  of  blood  not  larger  than  a  pin  head  to  collect  at  the 
site  of  puncture.  Touch  the  drop  with  one  of  the  cover-slips, 
quickly  drop  the  other  upon  it  and  gently  pull  them  apart  without 
exerting  pressure.  Or,  touch  the  drop  of  blood  with  one  of  the 
slides  near  its  end.  Place  one  end  of  the  other  slide  in  the  drop 
and  wait  for  a  second  or  two  until  the  blood  has  spread  across  the 
slide.  Then,  holding  the  second  slide  at  an  angle  of  about  30  de- 
grees to  the  first,  draw  it  gently  along  its  surface.  A  thin,  even 
smear  wall  thus  be  made.  The  smears  should  be  allowed  to  dry 
thoroughly  in  air  before  wrapping  for  mailing. 

RABIES  OR  HYDROPHOBIA. 

Because  of  the  increasing  prevalence  of  rabies  in  the  United 
States,  health  officers  should  have  a  very  definite  understanding 
of  certain  fundamental  facts  in  regard  to  the  laboratory  diagnosis 
of  this  disease.  For  it  rests  ultimately  with  the  laboratory  to  make 
clear  the  diagnosis  in  any  given  case.  The  following  regulations 
should  be  observed : 

Animal  Not  To  Be  Killed. — 1.  Do  not  kill  a  dog  or  other 
animal  immediately  after  it  Mtes  the  victim.  Shut  it  up  and  ob- 
serve it  for  ten  days.  If  it  remains  healthy  during  this  time,  this 
is  absolute  proof  that  the  animal  was  not  suffering  from  rabies, 
and  the  human  victim  is  in  no  danger  of  developing  the  disease. 
If  the  animal  shows  signs  of  illness  either  allow  it  to  die  naturally 
or  kill  it  after  three  or  four  days.  The  bite  of  a  dog  is  infectious 
from  1  to  5  days  before  symptoms  develop  and  before  Negri  bodies 
become  sufficiently  large  and  numerous  to  be  found  on  microscopic 
examination.  For  this  reason  the  animal  should  be  allowed  to  live 
until  the  disease  has  become  well  developed. 

2.  Do  not  shoot  the  animal  in  the  head.  If  the  brain  is  not 
completely  blown  out  of  the  head  by  so  doing  it  may  be  so  badly 
damaged  that  satisfactory  examination  is  impossible. 

3.  Send  the  ivhole  head  to  the  laboratory,  well  packed  in  ice 
in  a  water-tight  container.  If  the  head  is  not  kept  on  ice  the  brain 
may  become  so  soft  that  its  parts  cannot  be  recognized.  This  will 
greatly  hinder  satisfactory  examination. 

Examination. — When  the  head  is  received  at  the  laboratory  the 
brain  and  Gasserian  ganglion  are  removed  from  the  skull.  The 
brain  is  opened,  a  small  piece  of  the  hippocampus  major  (Ammon's 


PATHOLOGICAL    MATERIALS.  383 

horn)  is  removed,  pressed  between  two  glass  slides  and  smears 
made  on  several  slides.  These  are  stained  by  any  one  of  a  variety 
of  methods  and  examined  with  the  oil  immersion  lens.  Negri 
bodies,  if  present,  will  be  found  as  round  or  oval  granular  bodies 
inside  the  large  ganglion  cells.  If  these  are  not  found  a  guinea- 
pig  is  injected  subdurally  with  an  emulsion  of  the  suspected  brain. 
It  requires,  as  a  rule,  from  10  to  18  days  for  symptoms  to  show 
themselves  in  a  guinea-pig  inoculated  with  the  brain  of  a  rabid 
animal.  In  rare  instances  the  incubation  period  may  be  longer  than 
three  weeks. 

Negri  Bodies. — Negri  bodies  were  first  described  by  the  Italian, 
Negri,  of  the  University  of  Pavia,  in  1903.  Search  for  them  fur- 
nishes the  most  rai^id  and  satisfactory  means  of  diagnosing  rabies. 
In  general,  they  are  most  easily  found  in  the  brains  of  animals 
allowed  to  die  in  the  natural  cause  of  the  disease,  and  are  more 
difficult  to  find  the  earlier  in  the  course  of  the  disease  the  animal 
is  killed. 

The  finding  of  Negri  bodies  is  now  very  generally  recognized  as 
practically  conclusive  evidence  of  the  existence  of  rabies.  This  has 
been  confirmed  by  numerous  observations.  Luzanni  reports  459 
examinations  controlled  by  the  injection  of  guinea-pigs.  297  cases 
were  positive  by  the  biologic  test,  only  9  of  which  failed  to  show 
Negri  bodies.  Not  one  of  those  which  failed  to  kill  a  guinea-pig 
show^ed  the  bodies.  Poor  collected  550  similarly  controlled  cases 
from  the  records  of  6  European  laboratories.  Of  these,  344  showed 
Negri  bodies  and  all  were  positive  by  the  guinea-pig  test;  while  of 
206  which  showed  no  Negri  bodies,  11  were  found  positive  by  the 
guinea-pig  test.  Hence,  while  the  presence  of  Negri  bodies  in  the 
brain  of  an  animal  amounts  to  proof  of  the  existence  of  bodies,  "in 
failure  to  find  them  there  is  a  possibility  of  error  equal  to  5  per 
cent."^ 

Sections  are  made  of  the  Gasserian  ganglion  and  stained  in  the 
ordinary  way.  These  are  then  examined  for  round  cell  infiltration 
and  pericellular  endothelial  proliferation  with  destruction  of  the 
ganglion  cells,  conditions  found  with  considerable  regularity  in 
rabies. 


^  September,    1913,   Noguchi  is  reported  to  have  cultivated  successfully  the  microbe  of 

rabies,    which   is   a   protozoon   having   a   stage   so   minute    as   to  permit  it   to  pass  through 
a  porcelain  filter. 


384  PRACTICAL   SANITATION. 

VENEREAL  DISEASES. 

The  ignorance  of  prudery  in  regard  to  venereal  diseases  is 
rapidly  giving  place  to  knowledge  which  sets  the  true  value  upon 
these  social  plagues.  It  is  being  recognized  by  the  general  public, 
by  men  particularly,  that  the  latent  forms  of  these  diseases,  though 
capable  of  ruining  innocent  lives,  are  exceedingly  difficult  to  diag- 
nose clinically  and  that  certain  laboratory  tests  are  the  most  reliable 
means  of  detecting  them.  The  demand  upon  public  health  labora- 
tories for  such  tests  will,  therefore,  undoubtedly  continue  to  in- 
crease. 

1.  Gonorrhea. — Specimens. — In  order  to  secure  satisfactory 
examinations  for  gonococci  it  is  essential  that  the  specimens  be 
properly  secured  and  prepared.  Not  only  pus  from  the  urethra 
should  be  examined,  but,  before  a  male  patient  is  dismissed  as  cured, 
material  "milked"  from  the  prostate  gland  and  seminal  vesicles 
should  be  proved  free  from  gonococci  on  several  consecutive  exam- 
inations. 

Cover-glasses  and  slides  containing  gonorrheal  pus  should  never 
be  left  sticking  together.  This  is  the  condition  in  which  many 
specimens  of  this  kind  are  received  at  laboratories.  Such  a  speci- 
men will  dry  around  the  edges  and  the  pus  cells  in  the  central 
portion  of  the  "moist  chamber"  thus  formed  soon  become  so 
macerated  that  satisfactory  examination  is  impossible.  Contami- 
nating bacteria  will  multiply  to  such  an  extent  that  any  gonococci 
that  may  be  present  will  be  obscured. 

Contaminations. — Pus  from  a  chronic  vaginitis  always  contains 
contaminating  bacteria  in  such  enormous  numbers  that  the  detection 
of  gonococci  in  such  specimens  is  rendered  difficult  if  not  impossible. 
In  such  cases  smears  should  be  made  from  any  pus  that  can  be 
pressed  from  the  urethra,  or  taken  from  the  external  os  of  the 
uterus.  It  will  often  help  matters  to  reduce  the  excessive  bacterial 
flora  of  the  vagina  by  means  of  antiseptic  douches  applied  for 
several  days  before  taking  the  specimen. 

Reports. — The  report  from  the  laboratory  may  show  that  a  given 
specimen  was  either  positive,  negative,  doubtful  or  unsatisfac- 
tory. 

A  "positive"  report  can  mean  but  one  thing,  namely,  that  the 
pus  contained  gonococci  and  that  the  patient  has  gonorrhea. 

A  negative  report  has  not  the  definite  value  of  a  positive  finding. 


PATHOLOGICAL    MATERIALS.  385 

Two  or  more  consecutive  negative  results  should  be  obtained  before 
being  accepted  at  their  face  value. 

A  diagnosis  of  "doubtful"  is  all  that  can  be  justly  made  in  many 
cases,  especially  on  specimens  of  vaginal  smears.  Gram  negative 
diplococci  other  than  gonococci  are  sometimes  found  in  urethral 
and  vaginal  smears.  These  "pseudogonococci"  may  sometimes  be 
seen  inside  of  leucocytes.  They  do  not  occur  in  as  great  numbers, 
either  intra-  or  extra-cellularly,  as  do  gonococci  in  acute  and  sub- 
acute gonorrheal  infections.  It  is  in  the  chronic  and  latent  cases 
that  they  cause  the  most  confusion.  More  specimens  should  always 
be  sent  from  such  cases. 

An  unsatisfactor}'  specimen  calls  for  another  smear  from  the 
same  case. 

Vaginal  Pus. — Gonorrheal  infections  are  by  no  means  uncom- 
mon in  young  girls  from  1  to  10  years  of  age.  A  very  satisfactory 
method  of  obtaining  specimens  from  such  cases  is  as  follows :  Boil 
an  ordinary  medicine  dropper  in  water  for  several  minutes.  Draw 
a  few  drops  of  the  boiled  water  into  the  dropper  and  when  cool 
insert  the  tip  of  the  dropper  into  the  vaginal  orifice,  gently  expel 
the  water  into  the  vagina  and  draw  it  again  into  the  dropper. 
Any  pus  in  the  vagina  may  thus  be  easily  obtained  for  smears. 

2.  Syphilis. — The  methods  of  laboratory  diagnosis  of  syphilis 
consist  of  the  Wassermann  test  and  examinations  for  Treponema 
pallidum,. 

Wassermann  Test. — Very  fcAv  public  health  laboratories  in  the 
United  States  make  the  Wassermann  test.  The  impossibility  of 
obtaining  suitable  specimens  of  blood  from  any  large  proportion 
of  the  physicians  of  a  state  renders  the  doing  of  this  test  out  of 
the  question  for  state  laboratories.  The  principle  upon  which  the 
test  is  based  may  be  briefly  stated :  In  the  presence  of  its  antigen 
an  immune  serum  has  the  power  of  absorbing  complement  so  that 
if,  after  allowing  time  for  the  fixation  of  the  complement,  hemolytic 
serum  and  the  corresponding  red  blood  cells  are  added  to  the  mix- 
ture, no  hemolysis  takes  place  because  there  is  no  free  complement 
remaining.  Thus,  if  a  patient's  serum  be  mixed  with  syphilitic 
antigen  (e.g.,  extract  of  syphilitic  liver)  and  complement  (fresh 
guinea-pig  serum)  and  allowed  to  stand  for  a  time  and  then  a 
hemolytic  serum  and  the  corresponding  red  blood  cells  be  added, 
the  occurrence  of  hemolysis  Mall  depend  upon  whether  the  patient 
had  syphilis.     If  he  did  have  lues  his  serum  and  the  antigen  will 


386  PRACTICAL   SANITATION. 

combine  with  the  complement  and  no  hemolysis  will  occur.  If  he 
did  not  have  syphilis,  his  serum  and  the  antigen  will  not  combine 
with  the  complement  which  will  be  left  free  to  cause  hemolysis 
when  the  hemolytic  serum  and  red  blood  cells  are  added. 

Specimens  for  AVassermann  Test. — Since  the  test  depends  en- 
tirely upon  the  occurrence  or  non-occurrence  of  hemolysis  it  is 
evident  that  clear  colorless  serum  must  be  used.  The  amount  of 
each  ingredient  of  the  test  must  be  measured  with  the  greatest  ac- 
curacy. Dried  blood  is  therefore  of  absolutely  no  value  for  the 
tests.  At  least  2  c.c.  of  blood,  preferably  more,  must  be  obtained. 
This  is  best  taken  from  a  vein  at  the  bend  of  the  elbow.  The 
blood  is  allowed  to  clot  and  the  clear  serum  which  soon  separates 
may  be  sent  to  the  laboratory  in  a  sterile  tube. 

"When  a  siDccimen  of  blood-serum  is  sent  for  the  Wassermann 
test  some  facts  concerning  the  personal  habits  of  the  patient  should 
accompany  it.  This  will  aid  in  interpreting  the  result  inasmuch 
as  the  test  may  be  modified  by  a  number  of  factors.  Thus,  alcohol 
taken  in  considerable  quantities  will  render  the  strongest  positive 
serum  negative. 

Examinations  for  Treponema  (Spiroch^ta).- — Examinations 
for  Treponema  pallidum  are  much  more  practicable  for  public 
health  laboratories  especially  for  state  laboratories.  The  success 
of  such  examination  depends  very  largely  upon  the  manner  in 
which  the  specimen  has  been  taken.  Treponemas  may  be  found  in 
stained  smears  or  by  means  of  the  dark  ground  illuminator. 

In  securing  a  specimen  to  be  examined  for  Treponema  pallidum 
two  facts  should  be  remembered.  First,  the  superficial  portion  of 
the  discharge  from  a  chancre  or  mucous  patch  is  always  contami- 
nated by  innumerable  bacteria.  Second,  the  Treponema  pallidum 
is  a  strictly  anasrobic  organism  and  is  practically  never  found  on 
the  surface  next  the  air.  To  secure  a  satisfactory  specimen  the 
superficial  crusts  or  secretions  must  be  gently  removed  without 
causing  bleeding,  and  the  surface  irritated  gently  with  a  sterile 
swab  until  serum  exudes.  In  a  true  syphilitic  lesion  the  serum 
brings  with  it  from  the  deeper  tissues  large  numbers  of  Treponemas. 
The  serum  may  be  collected  in  spindle-shaped  bulbs,  such  as  are 
used  by  some  laboratories  for  taldng  blood  for  the  Widal  test;  or 
it  may  be  smeared  on  slides  or  cover-glasses  and  allowed  to  dry 
thoroughly  in  air  before  being  sent  to  the  laboratory.    Failure  to 


PATHOLOGICAL   MATERIALS.  387 

find  Treponema  pallidum  in  a  single  specimen  should  never  be 
considered  equivalent  to  a  negative  clinical  diagnosis  of  syphilis. 

LrETiN  Test. — The  luetiii  test  is  a  entaneous  test  similar  in  prin- 
ciple to  tlie  von  Pir([uet  tuberculin  test.  It  is  of  least  value  in  pri- 
mary and  secondary  syphilis,  and  should  always  be  checked  by  the 
Wassermann  test.  It  is  to  be  had  commercially,  and  should  be 
widely  employed. 

MENINGITIS. 

Diagnosis. — Public  health  laboratories  are  frequently  called  upon 
to  examine  cerebrospinal  fluid  for  meningococci.  In  state  labora-, 
tories  this  work  is  not  very  satisfactory  because  of  the  readiness  with 
which  meningococci  undergo  bacteriolysis  in  the  fluid  after  with- 
drawal. To  obviate  the  difficulties  as  much  as  possible,  the  phy- 
sician or  health  officer  should  make  smears  from  the  fluid  upon 
slides  at  the  bedside,  and  make  cultures  on  Loffler's  blood  serum 
if  available,  as  well  as  send  some  of  the  fluid  to  the  laboratory  in  a 
sterile  bottle. 

The  Minnesota  State  Board  of  Health  supplies  a  complete  outfit 
sterilized  and  ready  for  use  for  making  spinal  punctures  in  cases 
of  meningitis  or  poliomyelitis. 


APPENDIX. 

SCHEMES  FOR  SANITARY  SURVEY  OF  CITIES,  PUBLIC 
BUILDINGS  AND  SCHOOLS. 

SCHEDULE  FOR  SANITARY  SURVEYS  OF  CITIES.^ 
A.    Location,  Population,  and  Climate: 


Name  of  city county and  State 

Location latitude and   longitude 

Area   of  city 

When  was  city  founded  ? 

When  was  it  incorporated  ? 

Give   population    according   to   U.    S.    census    in 'I860.... 

1870 1880 1890 .1900 1910 

Present    ( estimated ) 

What  is  the  density  of  population  ? 

What  is  the  estimated  population  under  five  years  of  age? 

Give  population  according  to  whether  native  or  foreign  born  ? .  .  .  . 
according  to  whether  white  or  colored? 

What  is  the  number  of  dwelling  houses  of  the  city? 

What  is  the  average  number  of  persons  to  each  dwelling? 

Have  meteorological  observations  been  kept  regularly  in  the  city?. 

Who  made  the  observations? Have  they  been  published?. . 


B.    Topography  and  Geology: 

Altitude  of  city  ? on  what  authority  ? 

Give  highest  and  lowest  elevations  ? 

Is  the  surrounding  country  level  or  hilly  ? 

Are  there  any  marshes,  lowlands,  or  swamps  near  city? 

State  if  any  of  the  city  land  is  filled  or  made  land? 

Are  there  any  mountains  near  city;  if  so,  what  is  the  altitude? 

Is  the  site  of  the  city  level  ? hilly  ? 

Are  there  any  covered  up  watercourses  in  the  city  ? 

Have  any   original  watercourses  been   diverted   from   their   course,   or 

modified  ?    

State  if  there  are  any  ponds  or  other  stagnant  water? 

What  is  the  distance  of  the  city  from  tide-water? 

State  the  character  of  the  soil  and  of  the  subsoil? 

Describe  any  rivers,  lakes  or  canals  in  the  city  limits  ? 

Are  they  affected  at  all  by  the  tides  ? 

Is  the  water  of  the  streams  clean  or  foul  ? 


^Gerhard:   Guide  to  Sanitary  Inspection  —  John  Wiley  &  Sons,   1909. 

389 


390  APPENDIX. 

Does  any  foul  surface  drainage  or  sewage  enter  any  of  the  streams  ? . . 

Is  any  part  of  the  citj'  subject  to  overflows,  and  to  what  degree? 

To   what  geological  formation  does  the   site  of  the  city  and  vicinity 

belong  ?    

What  are  the  underlying  geological  strata? 

Are  they  permeable  or  impermeable  to  water  ? 

Does  the  disturbance  of  the  soil  cause  malaria? 

C.  Water-Supply : 

Describe  the  sources  of  water-supply  for  the  city 

Describe  the  character  and  degree  of  purity  of  the  supply 

Give  chemical  and  bacteriological  analyses  if  obtainable 

What  are  the  physical  characteristics  of  the  water-supply? 

What  is  the  distance  from  the  source  of  supply  to  the  city? 

Gravity    conduits  ? Pumping  ? 

State  capacity  of  the  conduit  ? of  the  pumps  ? 

How  many  reservoirs  are  there  ? 

State  capacity  of  each its  location elevation 

Do  the  waterworks  comprise  filtration  works? 

What  is  the  average  consumption  in  million  gallons  per  day? 

W^hat  is  the  maximum  consumption  ? 

What  is  the  average  daily  consumption  per  capita? 

What  is  the  average  water  pressure  in  the  city? 

What  is  the  maximum  ? 

How  many  fire  hydrants  does  the  city  have  ? 

How  many  public  fountains  ? 

How  many  house  connections  or  taps  ? 

Are  the  house  services  metered  generally or  what  is  the  propor- 
tion of  metered  to  unmetered  taps? 

To  what  extent,  if  any,  is  cistern  or  well  water  used  in  the  city? 

What  is  the  average  depth  of  the  wells  ? 

Are  the  wells  dug,  driyen,  drilled  or  bored? 

Are  there  any  artesian  wells  in  the  city? ' .  .  .  . 

Has  the  use  of  well-water  caused  any  sickness? 

How  many  public  baths? What  kind  and  type? 

What  is  the  average  daily  water  consumption  of  the  bath  liouses?.  .  . , 

D.  Drainag-e  and  Sewerage: 

What  is  the  proportion  of  closely  built-up  area  compared  with  the 
open  or  suburban  area  ? 

What  is  the  character  of  the  surface  drainage? 

Is  any  subsoil  drainage  provided? How  is  it  arranged? 

Are  cellars  in  any  part  of  the  city  subject  to  overflow  or  flooding 
during  or'  after  heavy  rainstorms? 

Does  the  city  have  a  regular  system  of  sewerage? 

Furnish  sewerage  map 

Is  the  city  sewered  on  the  combined  system? on  the  separate 

system  ? or  on  a  combination  of  both  ? 


APPENDIX.  391 

Give  the  mileage  of  sewers 

Give  number  of  sewer  outfalls 

State  their  size 

Where  do  the  sewer  outfalls  discharge  ? 

Are  the  city  sewers  self-cleansing? 

Are  flush  tanks  used  ? 

What  proportion  of  the  area  of  the  city  lacks  sewerage? 

State  the  number  of  house  connections? 

Describe  the  manner  in  which  the  house  connections  are  made  in  the 

street  ?     

How  are  the  street  sewers  ventilated  ? 

Is  the  plumbing  and  drainage  work  in  the  houses  governed  by  rules 

and    regulations  ? 

Are  the  sewer  connections  compulsory  where  a  street  has  been  sewered? 

Are  any  cesspools  tolerated? If  so,  how  are  they  constructed?.  . 

Describe   any   other    methods   of    disposal   of   the   waste   liquids   from 

houses  ?    

Is  there  any  regular  system  of  sewage  disposal  ? 

What  system  of  sewage  disposal  is  in  use? 

Describe  its  chief  features  ? 

Are  any  odors  ever  noticed  from  the  sewer  openings  ? 

Are  odors  perceptible  at  the  sewage  purification  works  ? 

E.    Streets  and  Public  Grounds : 

Give  the  total  number  of  miles  of  streets  ? 

State  how  many  miles  are  paved  with  granite  stones  ? 

With    asphalt? 

With   macadam  ? 

With  cobble-stones  ? 

With  wood  ? 

With  asphalt  paving-blocks  ? 

With  any  other  artificial  pavements  ? 

What  is  the  usual  width  of  the  streets  ? 

What  is  the  width  of  the  sidewalks? How  are  they  finished?.  .  . 

Are  the  streets  regularly  cleaned  by  the  city  ? 

Are  they  sprinkled  in  summer  ? 

Is  the  street  cleaning  method  satisfactory  ? , 

Is  hand  labor  used  exclusively  ? 

Are  any  sweeping-machines  used  ? 

Are  shade  trees  planted  along  the  streets  ? 

What  kind  ? How   arranged  ? 

Does  the  asphalt  pavement  injure  the  trees  ? 

Are  the  trees  unfavorably  affected  by  leakage  from  gas  mains? 

Who  cares  for  the  trees  in  the  streets  ? 

State  number  and  area  of  all  public  parks  ? 

How  many  smaller  open  squares  are  within  the  city  limits  ? 

Are  there  any  grade  crossings  in  the  city  ? 

How  many  lives  lost  annually  by  them  ? 


392  APPENDIX. 

Is  there  a  municipal  street  railway  system,  or  are  the  lines  owned  by 

private  companies  or  corporations? 

How  many  companies  are  there  ? 

What  system  of  electric  traction  is  used  ? 

State  number  of  accidents  on  trolley  lines  per  year 

F.    Habitations  and  their  Tenants : 


How  many  dwelling-houses  are  there  in  the  city? 

How  many  office  buildings? How  many  factory  buildings?.  .  . 

How  many  public  buildings  ? 

What  proportion  of  dwellings  is  occupied  by  the  owners? 

How  many  tenement-houses  are  in  the  city  ? .  .  ^ 

W'hat  is  the  average  number  of  persons  to  a  dwelling? 

Does  the  city  have  a  building  department? 

Are  there  any  building  regulations  ? 

Are  the  rules  enforced,  and  is  there  a  regular  system  of  inspection  ? .  . 

How  many  dwellings  are  connected  with  the  sewers  ? 

How  many  houses  are  connected  with  the  water  mains  ? 

Do  any  houses  use  wells,  springs,  or  rain-water  cisterns  for  supply  ? . . 

How  many  detached  buildings? How  many  houses  in  blocks?. 

Do  any  of  the  houses  have  damp  or  wet  cellars  ? 

Are  the  floors  of  the  cellars  cemented  ? 

What  is  the  usual  height  of  the  dwelling-houses  ? 

How  many  houses  in  city  are  without  bathtub  ? 

How  are  the  yards  kept  ? : 


G.    Lighting : 


Is  the  city  lighted  by  gas  ? 

Is  the  city  lighted  by  gas  and  electric  lights? 

Describe  the  location  of  the  gas  works  ? , 

Is  the  gas  plant  owned  by  a  private  corporation  or  by  the  city?.  . 

How  many  miles  of  gas  street  mains  ? 

What  kind  of  gas  is  supplied  to  the  users? 

What  is  the  price  charged  per  1000  cubic  feet  of  gas? 

Is  the  quality  of  gas  supplied  satisfactory  ? 

Is  it  tested  by  municipal  inspectors  or  gas-testers? 

What  proportion  of  dwelling-houses  are  supplied  with  gas? 

How  many  gas  accidents  have  occurred  within  a  year? 

Is  the  city  lighted  up  by  electric  light? 

Who  owns  the  electric  light  works ? 

Municipal   or  private  plant? 

What  is  the  capacity  of  the  plant? 

What  is  the  price  charged  for  electricity,  for  lighting? 

What  is  the  price  charged  for  electric  current  for  power  purposes?. 

Are  streets,  squares  and  parks  lighted  by  electricity? 

W^hich  is  the  better  system  of  street  lighting,  gas  or  electric? 

How  many  electric  lamps  are  there  in  the  streets? 


APPENDIX. 


393 


How  many  accidents  have  occurred  in  a  year  from  tlie  use  of  the 

electric  current  ? 

Other  modes  of  lighting? oil  in  lamps gasoline  lamps. 

Is  there  any  acetylene  lighting  plant  ? 

H.    Garbage  and  Refuse  Disposal: 

Is  the  household  garbage  removed  by  the  municipality? 

Is  it  removed  at  private  expense  ? 

How  often  is  the  garbage  removed? How  often  the  ashes? 

Is  garbage  removed  in  covered  vessels  or  carts? 

Are  ashes  and  garbage  kept  separate  by  ordinance? 

What  is  the  cost  per  annum  of  the  removal  ? 

Where  are  the  ashes  disposed  of  ? 

What  is  done  with  the  garbage  ? 

Any   reduction    plants  ? 

Any  refuse  destructors  ? 

Do  large  hotels  and  department  stores  have  their  separate  refuse 
destructors  ?    

Which  city  department  takes  care  of  the  removal  of  dead  animals?.  . . . 

How  are  the  carcasses  disposed  of  ? 

Is  the  work  done  satisfactorily  ? 

Are  any  houses  still  served  with  cesspools? If  so,  what  pro- 
portion ?    

What  is  the  construction  of  these  cesspools? leaching? 

water-tight  ?    

Are  any  cesspools  with  overflows  to  sewers  permitted? 

Are  there  municipal  rules  regarding  the  construction  of  cesspools  ? . .  . . 

How  often  are  the  cesspools  cleaned  out  ? 

Are  the  methods  pursued  satisfactory  ? 

Are  there  any  privy  vaults  attached  to  houses? 

How   many  ? 

Where  are  the  vaults  located  ? 

Are  there  any  municipal  rules  regarding  the  construction  of  the 
vaults  ?    

I.    Markets : 

How  many  public  markets  does  the  city  have  ? 

What  is  the  size  and  area  of  each  of  them  ? 

Where  are  the  markets  located  ? 

How  many  buildings  does  each  market  contain? 

Describe  construction  and  arrangement  of  the  markets  ? 

Are  the  market  stalls  rented  by  the  city  ? 

What  is  the  average  rental  per  year  ? 

On  how  many  days  of  the  week  are  the  markets  open  ? 

Are  the  markets  kept  in  a  cleanly  and  sanitary  condition? 

What  are  the  rules  in  force  regarding  the  cleaning  of  the  buildings  ? .  . 

How  often  are  the  markets  inspected  and  by  whom  ? 

What  are  the  principal  transportation  routes  for  the  fresh  food  sup- 
plies brought  to  the  markets  ? 


394  APPENDIX. 

J.    Slaughter-houses : 

How  many  slaughter-houses  are  located  in  the  city? 

•Are  they  built  by  the  municipality  or  by  private  owners? 

Are  there  municipal  rules  and  regulations  iu  force  regarding  the 
slaughter-houses  ?    

What  is  the  location  of  slaughter-houses  with  reference  to  the  city 
plan  ? 

Wliat  is  the  condition  of  the  water  supply  and  sewerage  of  the  build- 
ings ?    

What  is  the  mode  of  killing  the  animals? 

What  is  done  with  the  offal ? 

Is  any  nuisance  to  the  neighborhood  caused  by  the  slaughter-houses?. . 

What  is  the  average  annual  number  of  animals  slaughtered  at  the 
abattoirs? Of  each  kind?.  . , 

Is  there  any  fat  rendering  establishment  at  the  abattoir? 

How  are  the  noxious  gases  from  the  same  disposed  of? 

Are  private  slaughter-houses  permitted  in  the  city  ? 

What  is  the  average  annual  rental  of  the  slaughtering  stalls  to 
butchers  ?    

Is  there  any  official  meat  inspection  at  the  abattoir  ? 

Is  there  a  cold-storage  plant  connected  with  the  abattoir? 

K.    Manufactures  and  Trades : 

Are  there  located  within  the  city  limits  any  manufacturing  establish- 
ments which  constitute  a  nuisance  ? 

Do  any  of  the  factories  pollute  the  water-courses  ? 

Do  any  of  the  manufacturing  establishments  create  offense  to  the 
public  by  being  unduly  noisy  ? 

What  are  tlie  hours  of  labor  ? 

Is  there  any  factory  inspection  law? Is  it  enforced? 

How  is  the  ventilation  of  the  factories  ? 

L.    School-houses : 

How  many  public  schools  are  there  in  the  city? 

Where  are  they  located  ? 

State  for  each  of  the  schools  the  following: 

Location altitude  and  area  of  site nature  of  soil 

drainage date    of    erection cost    of   building 

Number     of     stories number     of     rooms number     of 

pupils    

(See  special  school  schedule  for  the  following  subjects:) 

Material  of  construction heating  apparatus ventila- 
tion system daylight  lighting artificial  light 

cloak-rooms basement playrooms toilets 

.  .  .  .water  supply drinking-fountains hours  of  study. 

Is  there  a  medical  inspection  of  the  school? 

Are  school  baths  installed? 


APPENDIX.  395 

What  are  the  results  obtained  with  them  ? 

Do  the  schools  have  a  gymnasium? Do  they  have  playgrounds? 

Are  the  water  closets  located  within  or  without  the  buildings? 

L.    Public  Libraries,  Museums,  Art  Galleries: 

Is  there  any  public  library  in  the  city? How  is  it  maintained? 

How  many  volumes  has  it  ? 

Is  there  any  public  museum  or  art-gallery? 

M.    Theatres,    Churches,   Amusement  Halls,   and  other  Public 
Buildings : 

(For  these  see  special  schedules.)  , 

N.    Hospitals : 

(For  these  see  also  the  special  schedule.) 

State  the  number  of  hospitals  in  the  city  ? 

Give  their  location  with  reference  to  the  city  plan  ? 

How  many  patients  do  each  accommodate? 

How  many  physicians  are  employed ? 

Does  the  hospital  have  an  ambulance  service  ? 

Are  any  of  the  hospitals  over-crowded? 

0.    Prisons,  Jails,  and  Police  Stations : 

How  many  policemen  are  on  the  force? 

Do  some  of  them  act  as  sanitary  inspectors? 

How  many  police  stations  are  there  ? 

How  many  prisoners'  cells  in  each  ? 

What  is  the  sanitary  condition  of  the  police  cells? 

What  is  the  average  daily  number  of  prisoners  ? 

Are  the  prison  cells  well  ventilated  ? 

Are  there  water-closets  in  the  cells  ? 

Where  are  the  lavatories  located? 

Are  there  any  spray  baths  for  the  prisoners  ? 

How  are  the  police  cells  heated  ? 

Is  there  a  police  matron? Is  there  a  police  surgeon? 

Have  there  been  any  outbreaks  of  epidemic  diseases  in  the  prisons?. .  .  . 

How  are  the  prison  inmates  occupied? 

What  is  the  estimated  number  of  prostitutes  ? 

How  many  drinking-saloons  are  there  in  the  city  ? 

Are  there  any  dance  halls  ? 

How  many  cases  of  drunkenness  are  brought  before  the  police  courts 
per  year  ? 

P.    Public  and  People's  Bath-houses: 

Is  there  a  municipal  system  of  public  baths  ? 

How  many  public  bath-houses  does  the  city  have? 

Where  are  they  located  ? What  was  their  cost  ? 

How  many  bath  units  in  each  bath-hoiise? 


396  APPENDIX. 

What  is  the  prevailing  form  of  bath  ? 

Tub  baths  ? Spray  or  rain  baths  ? 

Are  any  swimming-pools  connected  with  the  public  baths? 

Do  the  swimming-pools  have  cleansing  baths? 

If  city  is   located  on  a  river,   lake  or  the  ocean,  how  many  floating 

municipal  bath  establishments  are  there  ? 

Are  the  city  bath-houses  self-supporting  ? 

Is  any  admission  fee  charged  ? If  so,  how  much  ? 

Q.    Fire  Department : 

Is  there  a  municipal  paid  fire  department? 

Is  the  fire  service  performed  by  volunteers  ? 

How  many  fire  and  engine-house  stations  are  there  in  the  city? 

Does  the  fire  department  control  the  construction  of  buildings? 

How  many  steam  fire-engines  does  the  city  own? 

How  many  hook  and  ladder  companies  ? 

Is  the  water  supply  for  fire  purposes  satisfactory? 

If  the  city  is  on  a  river,  lake  or  harbor,  are  there  city  fire-boats  ? 

Is  there  an  auxiliary  high-pressure  system  ? 

Is  salt-water  used  for  fire  extinguishing  purposes  ? 

How  many  firemen  are  employed  in  the  fire  department? 

Is  there  an  insurance  patrol  service  for  saving  property  ? 

What  is  the  annual  number  of  fires  ? 

What  is  the  average  annual  property  loss  by  fire  ? 

What  is  the  annual  loss  of  lives  by  fire  ? 

What  are  the  chief  causes  of  fire  ? 

How  many  fire  alarm  boxes  has  the  city  ? 


R.    Public  Parks  and  Boulevards : 

What  is  the  total  acreage  of  public  parks? 

Where  are  they  located? 

Are  public  parks  and  squares  kept  in  good  condition  ? 

Are  there  any  comfort  stations  in  the  parks  and  squares? 

How  many? What  is  their  condition? Who  maintains 

them  ?   

S.    Cemeteries  and  Modes  of  Burial: 

Are  tlipro  any  cemeteries  within  the  city  limits? 

State  total  number  of  cemeteries  near  the  city? 

Arc  they  private  concerns  or  municipal? 

State  location  of  cemeteries  ? 

Describe  soil  in  the  cemeteries 

Is  it  well  and  thoroughly  underdrained  ? 

What  is  the  usual  average  depth  of  the  graves? 

What  is  the  number  of  burials  per  year  ? 

Are  all  the  burials  recorded  in  the  health  office? 

Are  otlier  modes  of  burials  permitted  or  practised? 


APPENDIX.  397 

T.    Public  Health  Laws  and  Ordinances. 
U.    Vital  Statistics  of  the  City: 

Are  births  and  deaths  recorded  ? 

What  is  the  annual  number  of  deaths  ?    

What  is  the  annual  number  of  births  ?    

What  is  the  birth  rate  ? 

What  is  the  death  rate  ? 

What  is  the  average  increase  per  annum  in  population  of  the  city?.. 

V.    Diseases  of  the  Year  and  Epidemics. 
W.    Disinfection : 

Does  the  city  have  a  municipal  disinfecting  station  ? 

Who  operates  the  plant  and  under  whose  control  is  the  same  ? 

Where  is  it  located  ? 

What  method  of  disinfection  is  practised  ? 

Are    houses    in    which   epidemic    diseases    occurred    disinfected   before 

any  new  tenants  move  in  ? 

At  whose  expense  is  the  disinfection  done  ? 

X.    Municipal  Sanitary  Expenses: 

Total  annual  appropriation: 

For  sanitary  purposes  ? 

For  sewerage  and  drainage  purposes  ? 

For  street  paving  ? 

For  street  cleaning  ? 

For  removal  of  garbage  and  ashes  ? 

For  care  of  markets  ? 

For  municipal   abattoirs  ? 

For  care  of  public  parks  and  fountains  ? 

For  public  comfort  stations  ? 

For  lighting  ?    

For  fire  department  services  ? 

For  police  department  services  ? 

For  building  department  services  ? 

SCHOOL-HOUSES.^ 

1.  Building,  how  located  as  to  elevation  and  drainage? 

2.  Size  of  house  ? 

3.  Is  it  brick  or  wood  ? 

4.  Has  it  a  cellar  or  basement  ? 

5.  If  so,  state  its  condition — whether  wet,  damp,  dirty,  dark,  unventilated, 

cemented,  or  floored,  etc.  ? 

*  From  New  Jersey  State  Board  of  Health's  Inspector's  Guide. 


898  APPENDIX. 

G.  Size  of   school-room? Give  number,   length,  bi'eadth,   and  height, 

that  the  cubic  space  may  be  computed ? 

7.  Is  there  an  entry  ? 

8.  Is  room  wainscoted? Kind  of  wall? 

9.  Number  of  doors  ? 

1 0.  How  many  windows  ? 

11.  Size  of  windows  and  glass  ? 

12.  Correct  answers  are  necessary  to  ascertain  lighting  surface 

13.  Distance  from  ceiling? 

14.  Are  the  windows  to  the  right  or  left,  behind  or  in  front  of  the  scholars?. . 

15.  What  is  the  size  of  the  yard  ? 

16.  Is  it  fenced? , 

17.  Does  water  ever  stand  in  the  yard  or  beneath  the  house? 

18.  Is  it  well  heated,  and  how? Is  there  dust? Is  water  sup- 

plied to  stove  or  furnace  ? 

19.  Do  you  register  by  thermometer? Is  temperature  even? 

20.  Is  it  well  ventilated,  and  how? If  by  ventilating  registers  state 

whether  they  are  in  the  ceiling  overhead,  or  in  flues  at  bottom  or  top 

of  room,  or  both Also,  if  there  is  any  provision  for  allowing 

fresh  air  to  enter  the  room  ? 

21.  If  by  windows,  have  you  any  ways  of  preventing  draught? 

22.  Are  the  blackboards  placed  between  the  windows? 

23.  Blackboards,  if  possible,  should  be  on  the  side  where  there  are  no  win- 

dows, on  account  of  less  reflection  of  light 

24.  Are  the  surfaces  in  good  condition? 

25.  What  is  the  source  of  water-supply  ? 

26.  If  from  wells,  give  depth Is  there  any  privy  vault,  stable  sink- 

drain,  or  cesspool  near  ? See  diagram,  and  mark  as  nearly  as 

possible,  the  distance  in  feet  from  such  sources  of  pollution 

27.  Is  the  well  protected  from  all  surface  pollution? 

28.  Is  the  condition  of  the  well  carefully  looked  after  ? 

29.  Are  there  two  privies  belonging  to  the  school-house? 

30.  How  many  feet  from  school-house  ? 

31.  Are  the  buildings  kept  in  good  order? 

32.  Have  they  vaults  ? 

33.  How  often  cleansed  or  disinfected  ? 

34.  How  is  it  done  ? 

35.  Do  trustees  or  others  inspect  buildings  and  school  monthly? 

36.  Have  you  a  janitor  ? 

37.  If  water-closets  are  in  use,  in  what  condition  are  they  kept? 

38.  Are  tlicy  always  flushed  with  an  abundance  of  water? 

39.  Are  they  odorless  ? 

40.  Are   there   any   ofi'ensive   or   dangerous   nuisances  near   the  school-house, 

such  as  barnyards,  slaughter-houses,  stagnant  pools,  etc.  ? 

41 .  Is  the  law  providing  for  vaccination  attended  to  ? 

42.  Are  pupils  from  families,  where  infectious  or  contagious  diseases  are  pre- 

vailing, excluded  from  school? 

43.  Are  all  the  doors  hung  to  swing  outward,  as  the  law  requires?. 


APPENDIX.  399 

44.  In  what  year  was  the  school-house  built  ? 

45.  Is  it  a  suitable  house  for  the  district? If  not,  state  reason  why 

Has  it  proper  places  for  hanging  garments,  hats,  etc.? 

46.  Are  tlie  seats  and  desks  fitted  to  the  size  of  the  scholars? 

47.  How  many  pupils  can  be  comfortably  seated  in  the  building? 

48.  Is  any  room  too  crowded  ? 

49.  What  i.'  thus  far  the  average  daily  attendance  this  quarter? 

50.  How  many  of  your  pupils  are  near  sighted? 

51.  Have  you  known  pupils  to  become  near-sighted  while  attending  school?.  . . 

52.  Are  there  curtains,  or  inside  or  outside  blinds,  to  the  windows  ? 

53.  How  and  to  what  extent  is  either  physiology  or  hygiene  taught? 

54.  Is  there  provision  for  hand-  and  face-washing? 

55.  General  remarks  as  to  needed  improvements 

INSPECTION  SCHEDULE  RELATING  TO  HOSPITALS.^ 

Hospital,  at 


1.  Date  of  examination 

2.  Location   

3.  Area  of  grounds  and  altitude  above  sea  level. 

4.  Character  of  soil 

5.  Arrangement  of  drainage 

6.  Are  sewers  connected  with  drains? 

7.  How  are  sewers  ventilated  ? 

8.  Grease  traps  ? 

9.  How  are  the  grounds  improved,  trees,  etc.  ? . .  . 

10.  General   character   of  buildings 

11.  Material  of  construction 

12.  Date  of  erection 

13.  Cost  of  buildings . . 

14.  Number  of  beds  for  patients 

15.  Wards,  general  character,  number 

16.  How  many  patients  in  a  ward? 

17.  Floor  area  per  bed 

18.  Cubic  space  per  bed?  

19.  Ward  floors 

20.  Ward  walls 

21.  Ward  windows . 

22.  Ward  doors  and  blinds 

23.  Ward  heating    

24.  Ward  ventilation 

25.  Ward  waterclosets 

26.  Urinals,    slopsinks 

27.  Ward  baths 

28.  Special    baths 

29.  Portable   baths 


^From  reports  of  New  Jersey  State  Board  of  Health. 


400  APPENDIX. 

30.  La\ atories,  separate  from  baths? !*..... 

31.  Ward  kitchens   

32.  Ward  -  dining-rooms i , 

33.  Ward  furniture 

34.  Bedsteads   

35.  Mattresses    

36.  Tables   

37.  Chairs   

38.  Spittoons    

39.  Medicine-trays    

40.  Bells    

41.  Patients'  clothing,  how  cared  for? 

42.  How  registered 

43.  Ward  physicians'  rooms 

44.  Ward  nurses'  rooms 

45.  Special  rooms  or  small  wards  connected  with  wards. 

46.  Nurses'   duties 

47.  Other  ward  attendants   

48.  Main  administration  building 

49.  Main  office 

50.  Visitors'  reception  rooms 

51.  Rooms  of  president,  physicians,  and  employees 

52.  Main  kitchen 

53.  Kitchen  furniture 

54.  Food  storerooms 

55.  Laundry   

56.  Laundry  appliances 

57.  Number  of  laundresses 

58.  Laundry  records  and  registers 

59.  Washing  for  employees 

60.  Linen  closets 

61.  Mending   

62.  Mattress  rooms 

63.  Disinfection   apparatus 

64.  Central  bathing  establishment 

65.  Dead   house 

66.  Amphitheatre   

67.  Ovit-door  patients'  dispensary  

68.  Number  treated  per  year 

69.  Cost    

70.  Dispensary  and  pharmacy 

71.  Lifts 

72.  Number  of  days'  treatment  of  patients  yearly 

73.  Total   annual   cost 

74.  Daily  r-ost  per  patient 

75.  Annual  cost  of   employees 

76.  Annual  cost  of  repairs 

77.  Annual  cost  of  fuel  and  quantity 


APPENDIX.  401 


78.  Annual  cost  of  medicines  and  apparatus 

79.  Annual  cost  of  food 

80.  How  is  the  hospital  governed? 

81.  How  are  the  governors  or  trustees  appointed?.  .  . 

82.  Superintendent:     Duties,  pay,  how  appointed?. 

83.  Nurses:     Male,  duties,  how  appointed,  pay?... 

84.  Cooks   

85.  Porters    

86.  Stewards    

87.  Clerks   

88.  Matron    

89.  Nurses,   female 

90.  Rules  for  admission  of  patients 

91.  Place  and  mode  of  admission 

92.  Rules  for  conduct  of  patients 

93.  Registration  of  patients 

94.  Registration  of  diseases 

95.  Registration  of  beds 

96.  Diet  forms 

97.  Permits  to  go  out 

98.  Rules  for  visitors 

99.  Special  wards 


Indiana  State  Board  of  Health 

DEPARTMENT  OF  FOOD  AND  DRUGS 


SANITARY  INSPECTION  OF  DAIRIES. 


DAIRY  SCORE  CARD. 

Owner  or  lessee  of  farm 

P.  0.  Address County 

Total  number  of  Cows Number  milking 

Gallons  of  milk   produced  daily 

Product  is  retailed  by  producer  in 

Sold  at  wholesale  to 

For  milk  supply  of 

Permit  No Date  of  inspection : ,  19 . 

PiEMARKS   , 


(Signed) 

Inspector. 
(FRONT  view) 

402 


DETAILED  SCORE, 


SCORE] 

METHODS. 

SCORE 

EQUIPMENT. 

o 

-d 

^ 

< 

< 

cows. 
Health    

Apparently   in   good   health.... 

i 

5 

6 

2 

2 
2 

COWS. 
Cleanliness    of    cows 

8 
6 

6 
2 

2 

If  tested  with  tuberculin  once  a 
year    and    no    tuberculosis    is 
found,  or  if  tested  once  in  six 
months    and    all    reacting    ani- 
mals   removed 

STABLES. 

Cleanliness    of    stables 

Floor    2 

Walls    1 

reacting    animals    found    and   re- 
moved,   2.)     ; 

Comfort    

Bedding     

Temperature  of  stable 

Food    (clean  and  wholesome)... 
Water     

Ceiling    and    ledges 1 

Mangers  and  partitions 1 

Windows    1 

Stable   air   at  milking  time 

Barnyard   clean  and  well  drained. 

Removal    of    manure    daily   to   field 

or   proper   pit 

(To  50  feet  from  stable,  1.) 

MILK    ROOM. 

Clean  and  fresh    

Convenient  and  abundant 

Location   of   stable 

"Well  drained 

Free    from    contaminating    sur- 
roundings      

Construction  of  stable 

Tight,    sound   floor    and   proper 

w 
30 

2 
4 

4 

3 
3 

... 

Cleanliness   of   milk  room 

UTENSILS    AND    MILKING. 

Care   and   cleanliness  of   utensils.  . 
Thoroughly    washed    and    steril- 
ized in  live  steam  for  30  min- 
utes        5 

3 

8 

9 

Smooth,   tight  walls   and  ceiling 
Proper  stall,   tie   and  manger.  . 
Light:  Four  sq.  ft.  of  glass  per  cc 
(Three  sq.  ft.,   3 ;    2   sq.  ft.,   2; 
1   sq.   ft.,    1.      Deduct   for  un- 
even  distribution.) 
Ventilation:   Automatic  system.. 

(Adjustable  windows,   1.) 
Cubic  feet   of   space    for   cow:    5 
to    1,000    feet ; . .  . 

(Thoroughly    washed    and    placed 
over      steam      jet,      4;      thoroughly 
washed    and    scalded    with    boiling 
water,    3 ;    thoroughly    washed,    not 
scalded,  2.) 

Inverted  in  pure  air 3 

Cleanliness    of    milking 

Clean,   dry  hands 3 

Udders   washed    and    dried.  ...    6 
(Udders  cleaned  with  moist  cloth, 
4;    cleaned  with  dry  cloth  at   least 
15   minutes  before  milking,    1.) 

HANDLING    THE    MILK. 

... 

(Less  than  500  feet,  2;  less  than 
400  feet,   1;  less  than  300  feet,   0; 
over  1,000  feet,  0.) 

Construction  and  condition  of  uten- 
sils     

Water   for    cleaning 

(Clean,      convenient,     and     abun- 
dant. ) 

Small-top    milking    pail 

Facilities  for  hot  water  or  steam.  . 
(Should  be  in  milk  house,  not  in 
kitchen.) 

Milk    cooler 

Clean  milking   suits 

1 
1 

3 

1 

1 
1 

•  •  • 

Cleanliness    of    attendants 

Milk     removed     immediately     from 

stable    

Prompt     cooling      (cooled     immedi- 
ately  after  milking  each  cow) .  . 
Efficient  cooling;   below  50°   F.... 

(51°  to  55°,  4;  56°  to  60°,  2.) 
Storage ;    below    50°    F 

51°   to   55°,   2;    56°   to   60°,   1.) 
Transportation;    iced    in    summer.. 

(For  jacket  or  wet  blanket  allow 
2 ;     dry   blanket   or   covered   wagon, 
1.) 

1 

2 

2 
5 

3 

3 

... 

MILK   EOOM. 

2 
2 

... 

1 

Free    from    contaminating    sur- 
roundings      

Convenient     

1 
1 

Floor,  walls,   and  ceiling 

Light,    ventilation,    screens .... 

1 
1 

Total     

40 

... 

Total     

60 

Score  for  equipment +     Score  for  methods = Final  score. 

Note  1. — If  any  filthy  condition   is  found,   particularly  dirty  utensils,   the  total  score 
shall  be  limited  to  49. 

Note  2. — If  the  water  is  exposed  to  dangerous   contamination  or  there  is  evidence  of 
the  presence  of  a  dangerous  disease  in  animals  or  attendants,  the  score  shall  be  0. 

(BACK  VIEW) 
403 


INDEX. 


INDEX. 


Abdominal   typhus,   G3 
Actinomycosis,    8G 
Acute   anterior   poliomyelitis,   156 
Acute    poliomyelitis,    38,    156 

definition,    156 

diagnosis,   156 

disinfection,    159 

etiology,   156 

modes    of   infection,    156 

pathology,    156 

prevalence,    157 

prodromes,   157 

prognosis,    158 

prophylaxis,    159    - 

quarantine,    159 

symptoms,   158 

types,    157 
Agglutination   tests : 

bacillary  dysentery,  70 

glanders,    123 

Malta  fever,  119 

jDaratyphoid,  67 

typhoid,   64,   376 
Agglutinins,  specificity  of,  376 
Ague,   131 
Air,  21 

not  important  disease   carrier,   21 
Anaphylaxis,    107 
Animal  parasites,    186 
Anthrax,    19,   21,    120 

bacilli,   19,   120 

definition,    120 

diagnosis,   121 

disinfection,   122 

etiology,     120 

external,    120 

incubation,    120 

malignant  edema  of,   121 

malignant   pustule,    120 
internal,    121 
intestinal,    121 

pathology,    120 

prognosis,    121 

prevalence,    121 

prophylaxis,    122 

quarantine,    122 

symptoms,    120 

synonyms,  120 
Anti-fly  campaigns,  280 


Anti-spitting  ordinances,   359 
Antitoxin: 

cholera,   7 1 

diphtheria,    108 

plague,    117 

rash,   107 

scarlet  fever,   97 

tetanus,   144 
Asiatic  cholera,   see  Cholera,   Asiatic 
Autumnal  fever,  63 

B 

Bacillvis   of: 

anthrax,    19,    120 

conjunctivitis,    183 

diphtheria,   104,   367 

glanders,    122 

hospital  gangrene,   138 

influenza,   110 

leprosy,    147 

plague,   116 

tetanus,   19,  85,  139 

tuberculosis,    141 

typhoid,   19,  63,  376 
Barber's  itch,   180 
Beriberi,    176 

definition,   176 

distribution,    176 

etiology,  176 

prognosis,    177 

prophylaxis,    177 

symjitoms,   177 

synonym,    176  , 
Bedbug,   22,    196,    198 
Birth  records,   203,   207 

certificates,   210 

checks  on,   207 

form,  208,   209,   212,  213 
Black  Death,   115 
Black   Plague,   115 
"Bloody   Flux,"   68,  70 
Boiling,   as  disinfectant,   53,   54 
Breakbone   fever,    135 
Brill's  disease,   152 
Bulletins,   205 


Camp   fever,    150 

refugee,  363 
Camphor-paraform, 

-phenol,   290 


59 


407 


408 


INDEX. 


Carbolic  acid,  55 
Carriers,  20 

Asiatic   cholera,    20,   71 

diplitlieria,   20,   371 

intorniittently    dangerous,   20 

malaria,    20 

typhoid,   20,   60,   379 
Catarrlial   fever,   110 
Causes  of  deatii,  International  list  of, 

225 
Cereals,   standards  for,   322 
Cerebrospinal  fever,   150 

abortive  form,    102 

chronic    form,    103 

complications,    103 

course,  102 

definition,   159 

diagnosis,    104 

diplococcus  intracelkilaris,  159,  100 

disinfection,   105 

epidemics,  159 

eruption,    162 

etiology,  159 

intermittent  form,   103 

Kernig's   sign,    104 

lumbar    puncture,    164 

malignant  form,   101 

mode  of  infection,   159 

ordinary   form,    101 

pathology,   160 

prognosis,    165 

prophylaxis,   165 

quarantine,    105 

special   senses  in,   163 

symptoms,    161 

synonyms,   159 
Cerebrospinal    meningitis,    159 
Chancroid,    166 
Chickenpox,   28,   38,   SI,   82,  91 

comidications,    92 

definition,  91 

diagnosis,   81,   82,    92 

etiology,   9 1 

incubation,    91 

mortality,  92 

quarantine,   92 

symptoms,   92 

synonym,   91 

varieties,    92 
Chills   and   fever,    131 
Chloride  of  lime,  55 
Cholera,    Asiatic,   20,   21,   26,   28,   37, 
63,   68,  71 

collapse,  72 

definition,   71 

dificrcntiation,  73 

disinfection,    73 

distribution,   71 

etiology,   71 


Cholera,  Asiatic —  ( continued ) 

immunity,   72 

incubation,  72 

modes  of  infection,  72 

pathology,   72 

preliminary  diarrhea,   72 

reaction,  73 

sicca,   73 

symptoms,    72 
Cholera  nostras,  73 
Clearance  slips,   27 
Conjunctivitis,   38,   182 

gonorrheal,    109,   184 

granular,   182 

mucopurulent,    183 
Conjvmctivitis  group,    182 
Contact  infection,   20 

immediate,  20 

mediate,   20 
Coughs  and  colds,   38 
Cowpox,    83 
Cresols,  55 


D 


Dairies,   325 

inspection   of,   325,   402,   403 
Dandy   fever,    135 
Dead,  disposal  of,   243 

transportation   of,   244 
Deathrate,  children  under  5  years,  30 
Deatli   record,   203 
Deaths,   registration   of,   219 

essentials,   219 

importance,    219 

list  of  causes,  225 

standard   certificate,   219,   220,   221 
Dengue,    1 35 

definition,    135 

diagnosis,   136 

difi'erentiation,   80 

etiology,    135 

immunity,    136 

incubation,    136 

mosquito-borne,    135 

prognosis,   136 

jn-ophylaxis,    136 

quarantine,   136 

symptoms,   136 

synonyms,    135 
Desquamation : 

measles,  99 

scarlet  fever,  95 
Dhobie   itch,    180 
Diarrheal   diseases,   30 
Diazo   reaction,    05,    379 
Di]ihtheria,    20,    21,    22,    20,    28,    29, 
37,    103,    367 

atypical  forms,   105 


INDEX. 


409 


] )  i  ph  tl  1  er  i  a^ —  (continued ) 

antitoxin,   108 

bacillus,   104 

can-iers,   103,  371 

conmiunity    propliylaxis,    108 

complications,    107 

cultures,  368,  3G9 

definition,    103 

diagnosis,    107 

dipiitlicroid  diseases,   109 

disinfection,   109 

etiology,    103 

habitat,   103 

heart  in,   105 

incubation,    109 

individual    prophylaxis,    109 

kidneys   in,    105 

Klebs-Loffler   bacillus,    104 

laryngeal,    106 

latent,   106 

lungs  in,  105 

membrane,   104,   105,   106 

modes  of   infection,   103 

nasal,    106 

onset,   105 

paralysis,   107 

pathology,    104 

persistence  of  infection,  372 

pharyngeal,    105 

predisposing  causes,    105 

prognosis,    108 

quarantine,    1 09 

rash  from  antitoxin,   107 

symptoms,    105 

synonym,  103 

systemic    infection,    106 
Diphtheria  group,    103 
Disinfection,  53 

clothing,   39 

contacts  and  convalescents,  39 

expenses,   how   taxed,   62 

person,   39 

responsibility   for,    62 
Disinfection  by    (see  Fumigation) 

bichloride  of  mercury,   54 

boiling,   54 

carbolic   acid,   55 

chemical  disinfectants,   54 

chloride  of  lime,  55 

cresols,   55 

dry  heat,  54 

fire,  53 

formalin,   55 

streaming  steam,   54 

superheated  steam,   53 
Drinking  cups,   common,   259 
Dosage  of  infection,   22 
Droplet   infection,    21 

in  leprosy,   148 


Droplet  infection —  ( continued ) 

scarlet   fever,   93 

smallpox,   75 

tuberculosis,    142 

whooping   cough,    1 1 1 
Dvmidum    fever,    154 
Dust   infection,    21 
in    cholera,   72 

leprosy,    148 

tuberculosis,    142 

typhoid,    64 
Dysentery : 

amebic,  20,  21,  68 

community    prophylaxis,    70 

definition,   68 

distribution,    68 

etiology,    68 

individual  prophylaxis,  70 

liver   abscess,   68 

pathology,   68 

prognosis,  69 

symptoms,   69 

synonyms,   69 
bacillary,   20,  21,  70 

definition,  70 

distribution,   70 

etiology,   70 

incubation,   70 

pathology,    71 

prophylaxis,   71 

symptoms,  70 


E 


Earthquakes,    362 
Eggs,   standard   for,   322 
Emergencies,    public,    361 

earthquakes,   362 

fire,   361 

flood,   361 

refugee   camps,    363 
Embalming  fluids,   246 
End  test  for  fumigation,   57,   61 
Entameba  histolytica,  68 
Enteric  fever,  63 
Eosinophilia  in  measles,  99 
Epidemic,   deflnition   of,   24 
Epidemic   paralysis,    156 
Epidemic  parotitis,  113 

complications,   114 

definition,    113 

etiology,   113 

incubation,   114 

prophylaxis,    114 

symptoms,    114 
Epidemic   poliomyelitis,    156 
Epidemics : 

established,    24 

inspection    of    schools    in,    26 


410 


INDEX. 


Epidemics —  ( continued ) 

inspectors,    lay,    25 
medical,    25 

laws  concerning,   30,   31 

management   of,    24 

special  hospitals,  26 

use  of  maps,  25 
Epidemiology,   17 
Erysipelas,    137 

definition,    137 

etiology,   137 

immunity,    137 

incubation,    137 

prophj'laxis,    138 

streptococcus   of,    137 

symptoms,    137 

synonyms,   138 
Estivoautumnal  fever,  131 
Exanthemata,   74 

comparative  table,  81 
Exanthematous   typhus,    150 


F 


Factories   and  workshops,  263 

buildings,  263 

cubic  space,  264 

dusty  occupations,  265 

employees,  265 

fumes,  265 

lighting,  263 

machinery,  264 

methods,    265 

stairs   and   fire   escapes,   264 

toilets,  264 

ventilation,   263 
Famine  fever,    152 
Farcy,    122 
Favus,   180 
Febris  recurrens,    152 
Fever  and  ague,  131 
Filaria,    195 
Filariasis,   195 

mosquito-borne,   22 
Filatow-Dukes  disease,   102 
Fire  as  disinfectant,  53 

public  emergencies  in,  361 
Flea,  22,   198 
Floods,   361 
Flukes,    186 
Flux,  68,  166 
Fly,  22,  280 

classification,    282 

diseases   carried.   281 

life  history,  288 

paper,   285 
poisons,    283 
poliomyelitis,  280 
prevention   of   breeding,   282 


Fly —  ( continued ) 

sanitary  importance,  280 

traps,  283 

typhoid,  281 
Fomites,   20 
Food,   22 
Food  inspection,   315,   318 

condemnation  of  foodstufTs,  318 

food    poisoning,    323 

general    principles,    315 

health  of  employees,   322 

laws,   315 

meats,  319-321 

milk,  325 

schedules,    316,    317,    318 
Foot-and-mouth   disease,    124,   320 

definition,    124 

etiology,    124 

incubation,   124 

prognosis,   124 

prophylaxis,    124 

symptoms,   124 

virus  filterable,   124,   156 
Formaldehyde  disinfection,   59 

by  spraying,   59 

camphor   insecticide,   59 

permanganate   method,   59 

solid,  60 
Formalin,  56 

in   milk,   339 
Fourth   disease,   102 
Frambesia,   166 
Fruits,   standard  for,   322 
Fumigation,  56,   277 

end-test,   57,   61 

expense  of,  58 

formaldehyde,  59 

hydrocyanic   acid,    60 

paraform,   60 

sulphur,   58 

unit  of,  57 

G 

Garbage  disposal,  312 

dumping,   312 

manure,   313 

nuisances,   312 
Glanders   and   Farcy,    122 

acute  forms,  123 

chronic  forms,   122 

definition,    122 

diagnosis,    123 

disinfection,    124 

etiology,   122 

farcy  buds,   122 

incubation,   123 

pathology,    122 

pneumonia,   123 

prevalence,   124 


INDEX. 


411 


Glanders  and   Farcy — (eontimicd) 

prognosis,   123 

prophylaxis, ,  124 

quarantine,    124 

symptoms,   123 

synonym,  122 
Gonorrhea,   168,  384 

complications,    109 

definition,   168 

prophylaxis,    169 

symptoms,   168 
Granular  conjunctivitis,   182 
Granulated   eyelids,    38 
Grippe,   110 

H 
Heat,  dry,   as  disinfectant,   55 
Hookworm,   19,   188-197 

disease,   190 

diagnosis,   190-193 

symptoms,   190 

treatment,    193 
Hospitals,   contagious  disease,  26,   34 

accounts,   49 

contacts    and    convalescents,    46 

construction,    41 

dining  room,  44 

discharge  certificate,   216 

dispensary,   45 

electric  wiring,  48 

food,   48 

guard  room,  45 

heating,  43 

incinerators  and  crematories,   46 

kitchen,   44 

laundry,   44 

lavatory,   44 

laws,    51 

moisture,   43 

morgue,   45 

nurses'    quarters,    45 

organization,    41 

physician's    quarters,    45 

recapitulation,  50 

sewerage,   45 

sinks  and  vaults,  45 

sterilizing  rooms,   45 

store  rooms,  44 

supplies,   46 

telephone,  48 

transportation,  49 

ventilation,   42 

wards,   43 

ward   supplies,   47 
Hydrocyanic   acid,   60 
Hydrophobia,   125,  382 

definition,    125 

diagnosis,    126,   382 

etiology,  125 


Hydrophobia —  ( continued ) 
incubation,    125 
Negri  bodies,   125,   383 
pathology,   125,   126 
prevalence,   127 
prognosis,    127 
prophylaxis,    126 
symptoms,    125 

I 

Immunization : 

cholera,    71 

diphtheria,    108 

hydrophobia,    126 

meningitis,   165 

jDaratyphoid,  67 

plag-ue,   117 

scarlet  fever,  97 

smallpox,  82,  83 

tuberculosis,    146 
Impetigo  contagiosa,  38,  179 

differentiate  from  smallpox,  81,  82 
Incineration,    311,   312,   364 
Indexes  to  records,  203 
Infantile  paralysis,    156 
Infection,   19 

aerial,  21 

contact,  20 

dosage  of,   22 

fomites,    21 

food,  22 

influences  adverse  to,  19 

insects,  22 

nature  of,   19 

never  de  novo,   19 

outside  body,   19 

sources  of,  19 

spore-bearing    organisms   in,    19 

water,  21 
Infectious  diseases,  records,  204,  214 
reduction  of  mortality,  28 

processes,  19 
Influenza,  38,  80,   109 

complications,    110 

definition,   109 

diagnosis,   111 

differentiate  from   smallpox,   80 

etiology,   110 

febrile  type,    110 

gastrointestinal  type,    110 

history,    109 

immunity.   111 

incubation,    110 

mortality,    111 

nervous  type,    110 

prophylaxis.    111 
Insecticides : 

camphor-paraform,  59 

camphor-phenol,   290 


412 


INDEX. 


Inspectors  during  epidemics,   26 
Institutions  and  prisons,  267 

buildings,  267 

food,  269 

infectious   diseases,   268 

inmates,  268 

plumbinof   and    drainage,    268 

police,  268 

ventilation   and   heating,   268 

water   supply,  267 
Intermittent   fever,    131 
Isolation  and  quarantine,   33 

degrees   of,    33 

history,  33 

of  sick,  34 

permanent,  34 
Itch,  38,   197 


Jail  fever,   150 


Kala-azar,  22,   154 
Koplik's  spots,  99 


Laboratory  methods,  365 
Laws  concerning : 

drinking-  cups,  359 

epidemics,  30,   31 

food,   315 

marriage,   360 

nuisances,  358 

pathological  materials  in  mails,  306 

sanitary    privy,    306 

spitting,   359 

sterilization   of   unfit,    360 
Tjeishmanniasis,    154 
Leprosy,   147 

anesthetic    form,    149 

bacillus,   147 

definition,   147 

diagnosis,    149 

disinfection,   149 

distribution,    147 

etiology,    147 

modes  of  infection,  148 
contagion,   148 
heredity,   148 
inoculation,  148 

pathology,    148 

prognosis,   149 

quarantine,    149 

tubercular  form,  148 
Leprosaria,    147 
Lighting,  Snellen  test  for,  263 
Lime,  56 


Local   records,   202 
Louse,   22,  38,    150,   197 
Lyssa,   125 

M 

Malaria,  29,   131,  381 

cachexia,    132 

clinical    course,    134 

definition,    131 

diagnosis,    135 

distribution,    131 

estivoautumnal,   132,   134 

etiology,   132 

mode  of  infection,   132 

mosquito-borne,   22,    131,    132,    135 

pathology,   133 

pernicious,    133 

Plasmodium,  132 

projahylaxis,    135 

quartan,    132,    134 

tertian,  132,  134 
Malignant  purpuric  fever,   159 
Malignant  pustule,   120 
Malta  fever,  21,  22,  119 

cocci,    19,    119 

definition,   119 

diagnosis,    119 

distribution,   119 

disinfection,   120 

etiology,   119 

incubation,   119 

predisposing  factor,   119 

prognosis,    119 

prophylaxis,    119 

quarantine,    120 

symptoms,   119 
Manure,  314 

Marmot  as  plague   liost,   115 
Marriage  laws,    360 
Measles,  21,  27,  28,  29,  37,  38,  81,  97 

abortive   form,   99 

attenuated  form,   99 

atypical   forms,   99,   100 

black,   100,   101 

bronchitis   in,    100 

broncliopneumonia   in,    100 

complications,   100 

definition,   97 

desquamation,    99 

diagnosis,    100 

disinfection,   101 

eosinophilia,   99 

eruption,  98 

etiology,  97 

French,   101 

German,    101 

hemorrliagic    form,    100 

immunity,    100 


INDEX. 


413 


Measles —  ( continued ) 
incubation,  98 

Koplil<'s   spots,   99,    101 

pathology,  98 
prognosis,    100 

prophylaxis,    101 

quarantine,    101 

symptoms,   98,   99,   100 

synonyms,  97 
Mediterranean   fever,    119 
Meningitis,   cerebrospinal,    159 

epidemic  cerebrospinal,   159 

spinal,    159 

tubercular,   164 
Meningitis  group,   156 
Methods,   epidemiological,    17 

statistical,   204 
Milk,  325 

adjusted,   328 

analysis  of,   340 

bacteriological    examinations,    341 
standards,   341 

boric  acid  in,  339 

chemical  analysis,  338 

chemical   standards,    328 

classification   of,   326,   327 

composition   of,    339 

cow  stables,  329 

cows,  330 

dirt,  visible,   344 

employees,    332 

epidemics    from,    343 

homogenized,    328 

infection   from,   22 

inspection,   340,   402,  403 

legal    requirements,    326 

leucocytes   in,    344 

licenses,   329 

milk  room,   330 

need  of   control,   325 

pasteurization,   326,    335,    337 

permits,   329 

public   health   authorities,   325 

raw  milk,  329 

receiving  stations  and  bottling,  333 

regulation   of   market,    328 

regulations,    334 

septic  sore  throat,   326 

stores,   334 

subnormal,    334 

supply  and  infant  mortality,  340 

tubercle  bacilli  in,   342 

utensils,  332,  343 
Mimms'   culicide,   290 
Miscellaneous   sanitary   laws,   359 
Missed  cases,  20 

measles,   20,   99 

scarlet  fever,   20,  94 

smallpox,   20 


Morbilli,  97 

Morbidity  reports,  214 

Mortality,  reduction  of,  in  infectious 

diseases,  29 
Mosquito,  286 

Anopheles,   22,    131,    134,   287 

anti-mosquito   work,   289 

apparatus   for   catching,   291 

classification,  286 

Culex,   22,    135,   287 

drainage,    288 

fumigation,   290 

life  history,  286 

natural  enemies,  288 

Stegomyia,   22,    129,   287 
Mountain  fever,  68 
Mumps,    113 

N 

Neapolitan  fever,   119 
Notifiable  diseases,   216 
Notification,   27 
Nuisances,  354 
Nurses,  27 
Nutritional   diseases,    172 


0 


Occupational  diseases,   218 
Ophthalmia : 

Egyptian,   182 

military,  182 

neonatorum,   184 


Paragonimus,  186 
Paratyphoid  fever,   63,   67 
diagnosis,  68 
distribution,   67  , 

etiology,  67 
pathology,   67 
prognosis,   68 
prophylaxis,   68 
symptoms,  67 
Parotitis,  epidemic,   113 
Pathological  materials,  365 
collection  of  specimens,  366 
diphtheria,    367 

cultures,    368,   369 

persistence   of    infection,    372 

summary,    373 
gonorrhea,  384 
hydrophobia,   382 

animal  not  to  be  killed,  382 

care  of  head,  382 

Negri  bodies,    383 
malaria,  381 


4U 


INDEX. 


Pathological    materials —  ( contimicd ) 

meningitis,   387 

postal   laws  concerning,   3015 

pus,   375 

syphilis,   385 

treponenia,    38G 

tiil)ereulosis,  374 
diagnosis,  374 
sputum   outfits,   374 

typhoid,    376 

blood   cultures,   378 
diazo  reaction,   379 
carriers,   379 
diflferential    media,    380 
stools,  380 
Widal   reaction,    376 

urine,   374 

vaginal  pus,  385 

venereal  diseases,  384 

Wassermann,    385 
Pellagra,  22,   172 

definition,    172 

diagnosis,   175 

duration,    175 

erythema,  175 

etiology,    172 

insanity,   174 

maize  in,  172 

prodromes,   173 

prognosis,   175 

prophylaxis,    170 

Simulium   fly   in,    172 

symptoms,   173 

typhoid  form,  175 
Personal   precautions,   38 
Pertussis,    28,    111 
Pestilential   fever,   150 
Pestis   liominis,    115 
Pestis,  minor,   116 
Petechial  fever,  150,  159 
Pets  as  disease  carriers,  39 
Phenol,   55 
Piroplasmosis,    158 
Placards,  38 
Plague,    22,    37,    115 

bacteriology,    116 

bubonic  type,   116 

community    propliylaxis,    117 

definition,    115 

diagnosis,   117 

disinfection,    118 

dust   infection,    116 

etiology,    115 

flea,   lie 

habitat,   115 

incubation,    116 

individual  prophylaxis,   117 

inode  of  infection,  110 

pathology',  110 


Plague —  ( continued ) 

pestis  minor,   116 

pneumonic  type,   117 

Ijrognosis,    117 

quarantine,    118 

rats  in,  115,   116,   118 

rodents  in,   115 

septicemic   form,    117 

sj'mptoms,    115 

A'arieties,    116 
Plague,   bubonic,    115 

black,   115 

group,   115 

Oriental,  115 
Plasmodium,  132 

development,  132 

malariae,   132 

mosquito-borne,   22,    131,   132,    135 

praecox,   132 

vivax,   132 
Poliomyelitis,    acute    anterior,    156 
Plural   infections,    27,    96 
"Polio,"   156 

Population,   calculation   of,    205 
Preservatives : 

in  food,  322 

in  milk,  338 
Privy,   sanitary,  292 

disease   transmission,   292 

how  not  to  build,  295 

how  to  build,  295 

soil  pollution,   292 
Purpura  variolosa,  78,  82 
Putrid  fever,   150 

Q 

Quarantine   and   isolation,   33 
degrees   of,   33 
modified,  37 
permanent,  34 
strict,  34 

R 

Rabies,  125 
Rat,  270 

as  plague  carrier,  115,  llO,   118 
domestic  animals  as  enemies,   276 
fumigation,   277 
micro-organisms,   278 
natural  enemies,  272 
organized   action,   278 
poisons,   275 

arsenic,  276   - 

liarium   carbonate,   275 

phosphorus,  276 

strychnine,   270 
ratproof   buildings,   270 
sanitary   importance,    270 


INDEX. 


415 


Rat — (continued) 

species,  270 

starving-out,   271 

summary,  278 

traps,   272 
barrel,  273 
cage,  272 

fence  and  battue,  275 
figure-4,    273 
guillotine,    272 
pit,   273 
Rayfungus,    19,   86 
Records,  importance  of,  202 

loose  leaf,  203 
Refugee   camps,   363 
Relapsing    fever,    African,    22 
Relapsing  fever,  European,    152 

complications,   153 

definition,   152 

differentiation,   153 

disinfection,    154 

distribution,    152 

incubation,    153 

insect-borne,    22,    153 

pathology,   153 

predisposing   factors,    153 

prodromes,  153 

prognosis,    153 

prophylaxis,    153 

quarantine,   153 

spirillum   of,   152 

symptoms,    153 

synonyms,   152 
Remittent  fever,   131 
Ringworm,   38,   180 

group,   179 
Rock  fever,   119 
Rocky  Mountain   fever,   22 
Roseola,   epidemic,   101 
Rotheln,   101 
Roimdworms,   187 
Rubella,   38,   101 

etiology,   101 

prophylaxis,   102 

s>Tnptoms,   101 

synonyms,   101 
Rubeola,  97 

notha,   101 


S 


Sanitary  service,  organization  of,  199 
vScarlatina,    92 

Scarlet  fever,   21,  26,  27,   28,  29,   37, 
38,  81,  92 

albuminuria,   94,   95 

anginose  form,   95 

arthritis,    95 

chorea  in,  94 


Scarlet  fever —  ( continued ) 

coexistent  diseases,   96 

community    prophylaxis,    97 

complications,   95 

definition,  92 

desquamation,  95 

diagnosis,  96 

differentiation,   81,   96 

disinfection,  97 

distribution,   93 

ear   in,   96 

eruption,   93 

etiolog;y%   93 

hemorrhagic  form,   93 

incubation,    93 

malignant  form,  93 

mild  form,  93 

mode  of  infection,  93 

mortality,   96 

nephritis,  95 

onset,   93 

pathology,  93 

persistence  of  infection,  96 

prodromes,   93 

quarantine,   97 

relapses,    96 

sequelae,  95 

sera,  97 

synonyms,   92 
Scarlet   rash,   92 
School  buildings,  251 

arrangement,  251 

basement,   247 

care,  253 

cloakrooms,   248 

foundation,  247 

site,   247 

toilets,  248 

washrooms,   248 

water    supply,   248 
School  inspection,   26,  247,  253,  255 

forms   for,   258-262 

rules  for,   255-257 
Schoolrooms,   248 

blackboards,    251 

heating,  249 

humidity,  249 

lighting,  249 

space,   248 

ventilation,   248 
Scur-\^,  178 

definition,   178 

distribution,   178 

etiology,  178 

prophylaxis,   178 

symptoms,   178 

synonyms,  178 
Septic  group,    137 

tank,  309,  311 


416 


INDEX. 


Septic  sore  throat,   109 

definition,   109 

mode  of  infection,   109 

prophylaxis,    109 

milk  supplies,  326 
Serial   numbers  of  records,   204 
Seven-day  fever,   152 
Sewage  disposal,  308 

cesspool,  309 

incineration,   311 

septic   tank,   309 

sewer,  309 

water   closet,  309 
Sewers,  309 
Ship  fever,   150 
Simulium  fly,  22,   172 
Sleeping   sickness,    22,    128 

tsetse  fly  in,  22,  128 
Smallpox,   21,    26,   29,   37,   74,   81 

abortive  type,   78 

acne  in,  80 

albuminuria  in,  80 

boils  in,   80 

bronchitis   in,   80 

connnunity  prophylaxis,  82 

complications,   80 

confluent,   77 

definition,  74 

desiccation,   78 

diagnosis,  80 

diarrhea,  80 

difl'erentiation,    81,   82 

discrete,   77 

disinfection,  83 

ears  in,  80 

epidemics,  79 

eruption,  78 

etiology,    74 

eyes   in,   80 

gangrene,   80 

heart  complications,   80 

hemorrhagic   forms,    78,   79 

liistory,  74 

incubation,  76 

individual   prophylaxis,   82 

initial  rash,  77 

pathology,   76 

pneumonia,   80 

pock,   76 

prognosis,  82 

quarantine,  82 

synonyms,  74 

transmission,  75 

vaccination,   83 

variola      pustulosa      hemorrhagica, 
79 

variola  vera,  76 

varioloid,  79 
Spinal  meningitis,   159 


Spirillum,   cholera,    19 

relapsing  fever,   152 
Spiroehsete   obermeieri,    152 
Spores,  bacterial,  19 
"Spotted  fever,"   159 
Squirrel  as  plague  host,   115 
Standard  tables,   205 
Statistical  methods,  204 
Steam,  streaming  as  disinfectant,  54 

superlieated,    53 
Sterilization   law,   360 
Streptococcus  erysipelatis,   137 

pyogenes,   137 
Sulphate  of  iron,  56 
Sulphur  fumigation,   58 
Syphilis,  167 

definition,  167 

diagnosis,    168,    385,    386 

etiology,   167 

incubation,   167 

prognosis,   168 

prophylaxis,    168,   169 

spirochete   of,   167,   386 

symptoms,   167 

treponema,   166,   167,   386 

Wassermann  reaction,   167,  385 

T 

Tape^vorms,   187 
Tetanus,  19,  139 

antitoxin,    140 

bacillus,    19,    139 

definition,    139 

diagnosis,    140 

etiology,    139 

incubation,    139 

pathology,   1 39 

prevalence,   140 

prophylaxis,    140 

sjnnptoms,    139 

vaccination,  85 
Tabardillo,   150 
Ticks,   197 
Tinea,   179 

tonsurans,   38 

versicolor,    180 
Trachoma,  182 

definition,   182 

isolation   in,    183 

onset,    182 

symptoms,    182,    183 

synonyms,    182 
Trichina   spiralis,    189 
Trichinosis,    189 
Tropical   cachexia,    154 
Tropical  splenomegaly,   154 

definition,   154 

distribution,    154 


INDEX. 


417 


Tropical    splenomegaly —  ( continued ) 
mode  of  infection,   155 
parasite,    154 
prognosis,    155 
propliylaxis,   155 
syni])tonis,   154 
svnonvnis,    154 
Tsetse   fiy,   22,    128 
Tuberculosis,  21,  22,   141 
artificial   immunity,    140 
bacillus,   141,   142 
definition,   141 
diagnosis,    144,    145 
disinfection,    147 
distribution,    142 
etiology,   141 
group,   141 
infection,  factors,   favoring,    143 

modes  of,   142 
congenital,    142 
ingestion,    142 
inhalation,    142 
inoculation,   142 
isolation,   146 
not   invaccinated,    86 
pathology,    143 

caseation,   144 

changes  produced  by  bacilli,   143 

distribution  of  lesions,  143 

sclerosis,    144 
prophylaxis,   145 
pulmonary,   30 
race,    142 
symptoms,   144 
tuberculin  reactions,   144 

Calmette's,    144 

hypodermic,   144 

Moro,  145 

A'on  Pirquet's,   145 
"Typho-malarial    fever,"    63 
Typhoid  fever,  20,  21,  29,  38,  63 
carriers,  63,  379 
community  prophylaxis,   66 
diagnosis,   64,   376 
diazo  reaction,  65,  379 
differentiation,    65 
disinfection,    67 
distribution,    63 
etiology,   63 

individual   prophylaxis,   65,   381 
pathology,   64 
predisposing  factors,   64 
prodromes,    64 
prognosis,   65 
quarantine,   65 
sequelfe,   65 
symptoms,   64 
synonyms,  63 
termination,  65 


Typhoid   fever —  ( continued ) 

vaccine,   65,   381 
Typhus  fever,  20,  26,  28,  37,  150 

atypical,   152 

body  louse  infecting  agent,  20,   150 

Brill's  disease,    152 

community    prophylaxis,    152 

diagnosis,    151 

differentiation,    151 

disinfection,    152 

distribution,    150 

etiology,    150 

incubation,   151 

individual   prophylaxis,    152 

pathology,    150 

predisposing   factors,    151 

prodromes,   151 

prognosis,    151 

quarantine,    151,   152 

symptoms,   151 

synonyms,    150 

termination,    151 


U 


Undulant   fever,    119 
Urine,   specimens  of,  374 


Vaccination,  84 

actinomycosis,   85 

by  mouth,  88 

complications,   85 

compulsory,  90 

evolution,  84 

incubation,   84 

method,   87 

objections  to,   89 

scars,   88 

tetanus,   84 

tuberculosis,   85 
Vaccine,  typhoid,   65,   381 
Vaccinia,    83 

choice  of  lymph,  80 

complications,    84 

constitutional    symptoms,    84 

definition,    83 

eruption,   84 

incubation,  84 
Varicella,   92 
Varioloid,   79 
Variola,   74 

Venereal    diseases,    prophylaxis,    169, 
384 

group,   166 
Ventilation,  test  for,  248 
Vermin  as  disease  carriers,  39 
Vital   statistics,  rules,   205 


418 


INDEX. 


W 


Water,  21,  345 
analysis,    345 

ammonia,  free,   350 
albuminoid,   350 

bacteriological,    348 

chlorine,   350 

examination  in  laboratory,  348 

samples,   347 

intgrmation  to  accompany,  348 

survey   necessary,    345 
boiled,   22 
closets,   308 
contamination,    352 
municipal  supplies,   351 
Whooping  cough,    28,   29,   38,    112 
catarrhal   stage,   112 
complications,   113 
definition,    112 
disinfection,   113 
etiology,    112 
immunity,    112 
incubation,   112 
paroxysmal   stage,    112 
pathology,   111 
prognosis,    113 


Whooping  cough —  ( continued ) 

prophylaxis,   113 

symptoms,   112 
Widal  test,   see  Agglutination 
Woolsorters   disease,   120 
Workshops,   263 


Yaws,    166 

Yellow  fever,  20,  26,   128 

definition,    128 

diagnosis,   130 

disinfection,    131 

distribution,   128 

etiology,   129 

immunity,    129 

incubation,    129 

mosquito-borne,  22,  129,  130,  131 

pathology,    129 

predisposition,    130 

prevalence,    130 

prognosis,    130 

prophylaxis,   130 

quarantine,   131 

symptoms,   129 

virus  filterable,   129,    156 


e.c. — Cubic    centimeter. 
cm. — Cubic   millimeter. 


ABBREVIATIONS  USED. 

mi. — Micron,   1/1000  of  a  millimeter. 


RA425 

Gardner 

PracticalsanUati^n^ 


ulV 


Nov  9 


tf^ 


